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.
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
3. Emergency Care
You go to a hospital emergency room with a sudden and serious condition, such as the symptoms of a heart attack or stroke. The emergency visit is already covered under most plans. But under the reform law, emergency room visits do not require preauthorization, and you cannot be charged extra for an out-of-network visit.
4. Mental Health Services
Many plans don't cover mental or behavioral health services, but that will change under the law. Patients may be billed around $40 per session. In some states, though, coverage may be limited to a set number of therapy visits per year.
Under the law, your insurer must cover your hospitalization, though you may have to pay 20 percent of the bill or more if you haven't reached your out-of-pocket limit. Some hospitals charge $2,000 a day for room and board alone, and $20,000 with medical services, so those bills can soar. This year, medical costs will help bankrupt 650,000 American households — including many who thought they had decent insurance until diagnosed with a serious illness.
6. Rehabilitative and Habilitative Services
If you are injured or become ill, many plans today cover rehabilitation therapies to relieve pain and help you regain your ability to speak, walk or work. The plans often cover medical equipment, too, including canes, knee braces, walkers and wheelchairs. Few plans, however, address the reform law's essential requirement for "habilitative" services, which are therapies to help overcome long-term disabilities, such as those that accompany a disease like multiple sclerosis.
7. Preventive and Wellness Services
Many experts believe this benefit could help rein in the nation's rising medical costs. The idea is to get people to see doctors and make healthier choices before they get sick and run up medical bills. For example, you may be allowed a free "wellness visit" annually with your doctor to discuss your health. Beyond that, the law instructs insurers to provide all of the 50 preventive services recommended by the U.S. Preventive Services Task Force at no extra cost.
8. Laboratory Services
While the law codifies the full set of preventive screening tests — including prostate exams and Pap smears — that individual and small-group insurers must cover, you can still be billed for "diagnostic" tests that doctors order when you have symptoms of disease. Costs can range from $20 for a lab test to 30 percent of a magnetic resonance imaging scan (MRI).
9. Pediatric Care
Under the law, children under age 19 will be able to get their teeth cleaned twice a year, as well as receive X-rays, fillings and medically necessary orthodontia. In addition, children under age 19 will be entitled to an eye exam and one pair of glasses or set of contact lenses a year. Relatively few health plans cover children's dental or vision services today.
10. Maternity and Newborn Care
The law classifies prenatal care as a preventive service that must be provided at no extra cost. And it requires insurers to cover childbirth as well as the newborn infant's care. These maternity benefits are a welcome breakthrough for young people, as two-thirds of individual plans have traditionally excluded this type of coverage.