The 10 essential benefits all health plans must cover under ObamaCare:
Starting 2014, ObamaCare requires all health insurance plans to include services from each of the 10 Essential Health Benefits categories. So if you have a policy that fails to have all 10 health benefits, you may be penalized, because technically, it is not considered insurance under ObamaCare.
What are Essential Health Benefits?
Essential health benefits are types of care one needs to prevent and manage sickness. Since ObamaCare emphasizes heavily on prevention and health management as important measures to control costs, insurance companies now must provide coverage in the 10 essential health categories, regardless of costs. However, the extent to which each of these benefits is covered will vary by plans.
Which groups will be affected by the new standards?
- Large groups (big companies with many employees) will not see a big difference in their policy coverage, partly because 80% of most large group insurance already include the 10 essentials.
- Individuals and small groups will see the most marked difference in their coverage, since prior to 2010, less than 2% of all plans provided all the 10 benefits. This is why many individuals will see their health insurance premiums increase, since now plans have to provide more services.
What are the 10 essential health benefits insurance must cover?
1) Preventative and wellness services and chronic disease management will be provided without copay. ObamaCare requires all the 50 procedures, as recommended by the U.S. Preventive Service task force, to be provided without copay on all plans. A few examples of services include well-women visits, domestic violence screening, depression screening, diet counseling, and immunization vaccines.
2) Maternity and newborn care--Care before and after the baby is born will be provided for free.
3) Mental health, substance abuse and behavioral treatment: This refers to substance abuse and addiction problems. Treatment consists of counseling and psychotherapy. Since such treatments require a long term commitment, many insurance companies may control this service by requiring copays and limiting the number of therapy sessions.
4) Services and devices to help people with injuries, disabilities or chronic conditions: Services include both rehabilitative (recovering past damaged skills, like the ability to speak or walk for stroke patients), and habilitative services (helping develop news skills, like speech therapy for kids). Plans must also help with cost sharing on the necessary devices needed for recovery.
5) Laboratory Services: This pertains to lab testing services that aid doctors with diagnosing injuries, diseases and monitoring treatment. Some lab testing services can be considered preventative, such as breast cancer screening or prostate exam, and so will be free.
6) Ambulatory Care (Outpatient Care): Refers to the types of care one receives without being admitted to a hospital, such as an office visit with a doctor or a clinic. Most insurance plans already covers this. So you won’t see big difference in coverage here.
7) Emergency Services: The main change here is that now you cannot be penalized for going out of network or not having prior authorization.
8) Hospitalization: This is the care one receives as a hospital patient, and includes a whole range of services—from surgeries and boarding to medications and nursing care—that a patient uses during his or her stay at a hospital. Under ObamaCare, plans must do more to cover costs. In the past, many plans didn’t do enough to address this, and many Americans are still unaware that a day in the hospital can cost can anywhere between $2,000 to $20,000 per individual. Thus, why hospitalization cost is the primary cause of bankruptcy for American families.
9) Prescription Drugs: All insurance plans now must have a prescription program, where at least one drug from every category and classification of federally approved drugs must be covered. To control for costs, insurance companies may cover only generic version of a drug when the generic becomes available, and exclude others if cheaper alternatives are available.
10) Pediatric Care: Dental and vision must be offered to children below 19. The plans requires two routine dental exams, an eye exam and corrective lenses each year.
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I wrote this blog to help people make smart health insurance decisions. I am a small business owner, a husband, and a dad to three boys, so I've seen firsthand how important understanding insurance decisions can be. As a co-founder of Take Command Health and a licensed health professional, I've been recognized as a leading expert on healthcare transparency and defined contribution arrangements (QSEHRA). I've been featured in the New York Times, Wall Street Journal, Dallas Morning News, Forbes and others. Learn more about me and connect with me on our about us page. Thanks!