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What are Essential Health Benefits?

The Affordable Care Act included a requirement that all non-grandfathered individual and small employer group plans must provide coverage for at least the following 10 catergories of benefits:

  • Ambulatory patient services

  • Emergency services

  • Hospitalization

  • Maternity and newborn care

  • Mental health and substance use disorder services, including behavioral health treatment

  • Prescription drugs

  • Rehabilitative and habilitative services and devices

  • Labratory services

  • Preventive and wellness services and chronic disease managment

  • Pediatric services, including oral and vision care

Plans must also meet emergency network coverage requirments (for example, the plan may not require prior authorization and must apply the same benefits for out-of-network emergency services as in-network emergency services).

Questions About the Reform Coverage:

What preventive services are now included under the ACA?

Preventive services that must be covered at no additional charge in-network now included:

  • Preventive care for children up to age 16

  • All generally accepted cancer creening, including breast, cervical and prostate

  • Preventive services and immunizations for children and adults.

What is Minimum Essential Coverage?

The type of coverage an individual needs to have to meet the individual mandate under the Affordable Care Act. This includes most individual market policies offered within a state, job-based coverage, Medicare, Medicaid, CHIP, TRICARE, VA and certain other coverage.

What is a Qualified Health Plan?

Under the Affordable Care Act, starting January 1, 2014, an insuance plan is considered a Qualified Health Plan (QHP) if it is certified by Marketplace Exchange in wish it operates, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket max expense amounts), meets actuarial value requirements and meets other requirements.

What is the Preventive Services for Women mandate?

Beginning August 1, 2012 additional preventive health services for women have also been added to the preventive services that must be offered without cost sharing under the Affordable Care Act (ACA). These services will be provided without a copayment, coinsurance or a deductible.

 

The covered preventive services for women include:

 

  • Well-woman visits -This would include an annual well-woman preventive care visit for adult women to obtain the recommended preventive services.

  • Gestational diabetes screening - This screening is for women 24 to 28 weeks pregnant and other pregnant women at high risk of developing gestational diabetes.

  • HPV DNA testing - Women who are 30 or older will have access to high-risk HPV DNA testing every three years, regardless of pap smear results.

  • STD counseling, and HIV screening and counseling - Sexually-active women will have access to annual counseling on HIV and sexually transmitted diseases.

  • Contraception and contraceptive counseling - Women will have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling. For contraceptives covered in the pharmacy benefit, all generics are covered with no copayment. Select brand name contraceptives may require a copayment if a generic is available, which may be waived for medical necessity. Breastfeeding support, supplies, and counseling - Pregnant and postpartum women will have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment.

  • Domestic violence screening - Screening and counseling for interpersonal and domestic violence should be provided for all women.

Can I be turned down for coverage if I have a pre-existing condition?

Not if you are currently under the age of 19. Beginning in 2014, a health carrier cannot reject any application for coverage based on medical history, regardless of age.

Can an adult child be eligible for dependent coverage if the adult child is not a fulltime student?

Yes. Adult children under 26 are able to remain on their parents' coverage regardless of full-time student status.

Are adult children who are married eligible for dependent coverage?

Yes, adult children under 26 are allowed to remain on their parents' coverage regardless of marital status. Note that a married dependent's spouse and any children are not generally eligible for coverage under a parent's plan. However dependent daughters are not usually covered for maternity.

Can an adult child be eligible for dependent coverage if the adult child is eligible for coverage through an employer?

Yes, the adult is still eligible for dependent coverage. This also applies to grandfathered plans in the first plan year on or after January 1, 2014.

What is Open Enrollment?

If you will not have health insurance coverage through your employer you will need to enroll in a new plan during Open Enrollment. Open Enrollment is an annual period of time set up to allow you to choose from available plans. Open Enrollment for health plans effective January 1, 2014 will begin on October 1, 2013 and end December 15, 2013. Individuals can also obtain health insurance with a later effective date through March 31, 2014.

 

Except for life-changing events, this Open Enrollment period is generally the only time individuals and families will be able to choose qualifying coverage each year.

 

Life-changing events may qualify you for a special enrollment period within 60 days of an event such as the loss of a job, death or birth of a covered member, marriage or divorce. Plans can be purchased on or off the Marketplace, but must be purchased on the Marketplace in order to use any available premium tax credits or subsidies.

 

Beginning in 2014, Open Enrollment periods will be held from October 15-December 7 of each year with an initial effective date of January 1 of the following year.

What are these new metal levels I keep hearing about?

Beginning with plans effective on or after January 1, 2014, the Affordable Care Act will require new individual and small employer plans offered on or off the Marketplace to provide coverage at designated "metal levels" - Platinum, Gold, Silver and Bronze.

Platinum plans have the most generous coverage, and bronze plans have the least generous coverage.

  • Platinum level plans pay 90 percent of benefits, on average

  • Gold level plans pay 80 percent of benefits, on average

  • Silver level plans pay 70 percent of benefits, on average

  • Bronze level plans pay 60 percent of benefits, on average

There is also a catastrophic plan only available in the individual market that will cover the essential health benefits plus three primary care visits per year. The catastrophic plan can only be sold to individuals under age 30 and individuals who are exempt from the individual mandate as a result of hardship.

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