The health care law requires all health plans sold to individuals and small groups (in most states, groups with no more than 50 employees) to cover certain important health care services, known as “essential health benefits.” While it requires coverage for each of these categories of benefits, the law does not name the specific services that must be covered or the amount, duration and scope of covered services.
1. Ambulatory Patient Services
Care you receive without being admitted to a hospital — for example, at a physician’s office, clinic or same-day surgery center.
2. Prescription Drugs
Drugs prescribed by a doctor to treat an acute illness, such as an infection, or an ongoing condition, like high blood pressure.
3. Emergency Care
Care for a sudden and serious condition, such as the symptoms of a heart attack or stroke. Under the health care law, emergency room visits do not require preauthorization, and you cannot be charged extra for an out-of-network visit.
4. Mental Health Services
Care to evaluate, diagnose and treat mental health and substance abuse issues. Many plans don't cover mental or behavioral health services, but that will change under the law. In some states, coverage may be limited to a set number of therapy visits per year.
Care you receive as a patient in a hospital, such as room and board, care from doctors and nurses, and tests and drugs administered during your inpatient stay.
6. Rehabilitative and Habilitative Services
Services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills. Plans must cover needed therapy and medical equipment, such as canes, knee braces, walkers and wheelchairs.
7. Preventive and Wellness Services
The health care law requires insurers to cover a range of preventive services recommended by the U.S. Preventive Services Task Force at no extra cost. Preventive or wellness services include immunizations and screenings for diabetes and certain cancers, such as prostate exams and Pap smears. However, you can still be billed for "diagnostic” tests that doctors order when you have symptoms of disease.
8. Laboratory Services
Testing blood, tissues, etc. to help a doctor diagnose a medical condition and monitor the effectiveness of treatment.
9. Pediatric Care
The essential benefits above, but provided to children. Including dental and vision services for children under age 19. The mix of services and common conditions treated are quite different for different age groups.
10. Maternity and Newborn Care
Care provided to women during pregnancy and during and after labor; care for newly born children. 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.
It’s time to learn more about the health care law. Go to www.HealthLawAnswers.org
Updated February 2014
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