"The most significant threat to our national security is our debt," Admiral Michael Mullen, Chairman, Joint Chiefs of Staff, August 27, 2010


Wednesday, November 20, 2013

Understanding Obamacare as a Mandate

Here is the list of “essential benefits” that a health insurance plan must contain to meet the standards of the Patient Protection and Affordable Health Care Act of 2009 (ACA) which is commonly known as Obamacare.

 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:       
  1. Outpatient Care - Most health insurance plans cover this already.
  2. 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.
  3. 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. 
  4. 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. 
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. Lab tests - Obamacare plans cover 100% of preventive tests, but not ones ordered if you've already been diagnosed with a disease.
  10. 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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