The essential health benefits
package must cover the following general categories of services:
·
Ambulatory
patient services
·
Emergency
services
·
Hospitalization
·
Maternity
and newborn care
·
Mental
health and substance abuse disorder services, including behavioral health treatment
·
Prescription
drugs
·
Rehabilitative
and habilitative services and devices
·
Laboratory
services
·
Preventive
and wellness services and chronic disease management
·
Pediatric
services, including oral and vision care
|
Each of those categories is subject to the following:
The
scope of benefits is to be determined by the Secretary of HHS and equal to the
scope of benefits under a typical employer-based plan. Nothing shall prevent a
qualified health plan from providing benefits in excess of the essential
benefits package.
Source: http://www.naic.org/documents/committees_b_Exchanges.pdf
That’s the government speaking – to be defined as we go along – mostly by HHS
secretary Sebelius and her successors. Here is a explanation of the ten
benefit categories:
- Outpatient Care - Most health insurance plans cover
this already.
- Emergency Room Services - Most plans cover this, but
may charge extra if you go to a hospital that's out of their network, or
go without pre-authorization. Obamacare plans don't charge extra.
- Hospitalization - Not all plans cover enough of this huge cost. Most people don't realize that a day in the hospital can cost between $2,000 - $20,000 a day. If you have a high-deductible plan, or a plan with a low maximum, you may be surprised by how much you wind up paying out-of-pocket.
- Preventive and wellness visits, as well as chronic disease management - Preventive care visits have no copay. Obamacare requires that all 50 procedures recommended by the U.S. Preventive Services Task Force be covered as preventive services. These include well-woman visits, domestic violence screening, and support for breastfeeding equipment and contraception.
- Maternity and Newborn Care - Maternity care is
categorized as preventive care, and must be provided without cost. Most
young people who don't have insurance will find this is a needed benefit
if they become pregnant.
- Mental and Behavioral Health Treatment - This
includes treatment for alcohol, drug and other substance abuse and
addiction. Patient co-pays could be as high as $40 a session, and the
number of therapist visits could be limited.
- Prescription drugs - Most plans offer this at a
cost. All plans listed on the exchanges will include coverage of at least
one drug in every category in the U.S. Pharmacopeia. Whatever you pay out-of-pocket for drugs will also count
toward your deductible, which is not true for all insurance plans now.
- Services and devices to help people with injuries,
disabilities, or chronic conditions - Most plans cover services and
equipment to help you recover from temporary injuries, like a broken leg.
Obamacare plans will also cover goods and services to help you maintain a
standard of living if you contract a chronic disease, like multiple
sclerosis.
- Lab tests - Obamacare plans cover 100% of preventive
tests, but not ones ordered if you've already been diagnosed with a
disease.
- Pediatric care - Most plans do not cover dental and vision care, which is covered by Obamacare plans.
We offer this information as a basis for both understanding
ACA and providing the background to grasp the significance of this change on health
insurance premiums going forward. This federal government mandate, ACA, and its "essential benefits package" presented above must be funded. It will be funded by those who remain able to pay their insurance premiums - for themselves, their families and all others who cannot or will not pay. It is no different than any other federal government "entitlement."
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