The law sets certain standards that all insurers must meet, and mandates that all health plans offered to those who buy health insurance on their own or in small groups include a set of "essential health benefits."
Although health insurance provided through large employers is not required to feature these essential benefits, many experts expect insurers to continue to upgrade their plans over time.
Prior to the law's passage, we saw "a race to the bottom, with insurers cutting benefits to lower premiums," says Shana Alex Lavarreda, Ph.D., director of health insurance studies for the UCLA Center for Health Policy Research. "The essential health benefits set a standard for insurance. Anything below that is not true health insurance."
These changes are welcome news to people ages 50 to 64 — especially the 9 million uninsured in that group, as well as the 4 million who buy health insurance on their own. A new study by HealthPocket, an independent research firm, found that less than 2 percent of existing individual health plans provide all 10 essential benefits. On average, today's plans offer 76 percent of the benefits.
Read on to learn exactly what the essential benefits are, and see what you'll be able to purchase once the new health insurance marketplaces open on Oct. 1.
1. Ambulatory Patient Services
This is the most common form of health care, often called outpatient care. You walk into a doctor's office, get treated and then walk out. Nearly all health insurance plans already provide this coverage. Details about the plans' networks and access to doctors will vary, but the law says the networks' size must be "sufficient."
2. Prescription Drugs
Many plans offer drug coverage only as an option at extra cost. But under the law, all individual and small-group plans will cover at least one drug in every category and class in the U.S. Pharmacopeia, the official publication of approved medications in this country. Drug costs will also be counted toward out-of-pocket caps on medical expenses.
The Affordable Care Act & You
As of Oct. 1, every state will have a health insurance marketplace, where consumers can shop for coverage. In addition to mandating that insurers in those marketplaces offer the 10 essential health benefits, the health care law also sets certain standards that all insurers must meet, whether they're providing health insurance through an employer or directly to individuals and small groups. The law:
- Eliminates lifetime limits on essential medical expenses;
- Prohibits insurers from dropping your coverage or raising your premiums if you get sick — or from denying coverage if you have a preexisting condition;
- Ensures that your child can stay on your health plan until age 26;
- Caps annual out-of-pocket medical and drug expenses up to an estimated $6,400 for individuals and $12,800 for families.
Learn more about the Affordable Care Act at HealthLawFacts.org
Learn how the law can specifically benefit you at HealthLawAnswers.org