Blog #6 Obamacare and the 10 Essentials
I’ve been hearing a great deal of mumbling about Obamacare and its supposed neglect of women and preventative services, most notably, cancer screenings. In actuality, these mumblings are just what they seem to be, mumbling, with little to no basis. Fact, there are 10 essential benefits that all health insurance plans must include under the Affordable Care Act.
These benefits include:
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.
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
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 according to the U.S. Department of Health and Human Services, 41 million people will able to take advantage of the free services. Although insurers may raise premiums to cover the cost of providing free preventive care, the estimated 1 to 2 percent rate increase would be offset by a reduction in consumers' out-of-pocket spending.
In one example, HHS says, a 58-year-old woman would save about $300 for recommended vaccines, tests and screenings.
Free preventive care services for adults include:
• diabetes screening
• colorectal cancer screening
• high blood pressure screening
• tobacco cessation counseling
• screening for depression
• dietary counseling
• HIV screening for those at risk of the disease
• screening for obesity and weight loss counseling
Services for men:
• cholesterol screening (35 years and older)
Services for women:
• mammograms every year
• cervical cancer screenings
• colorectal cancer screening
• osteoporosis screening
Also, some grandfathered plans may be exempt from the requirements because only new plans sold after Sept. 23, 2010, have to follow the requirement for free preventive care. If a plan has not significantly changed its benefits or premiums since the health reform bill was signed into law on March 23, 2010, it is exempt.
Lab work and scans
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).
Dental and vision care for kids
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.
Care for mothers and children
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.
Look for my next blog: Health Insurance Cooperatives such as Health Republic and The Freelancers Health Services Corporation