Before the enactment of the Affordable Care Act, also called ACA or Obamacare, under the guise of making health insurance more affordable, health insurers whittled away at the health services covered by individual and small group health plans. Slowly but steadily, health plans covered fewer and fewer services. Individual and small group health plans were a vulnerable target for health insurers. The purchasers of these plans do not have the same bargaining power a large employer does, and often were given insurance with substantially less favorable terms than large group policies. ACA was enacted in part to ensure that all individual and small group plans provide meaningful health insurance coverage.
To accomplish this goal, ACA requires all non-grandfathered health plans in the individual and small group markets to cover ten Essential Health Benefits. The Essential Health Benefits are:
- Ambulatory patient services – Medical treatment one receives without being admitted to a hospital. An example would be a check-up at a doctor’s office, or minor surgical procedures that do not require an overnight hospital stay. The size of a plan’s network may vary, but it must be “sufficient” to meet ACA guidelines
- Emergency services – Treatment in an emergency room when one needs care as soon as possible. ACA prohibits health plans from requiring pre-authorization for emergency services or from charging extra for out-of-network emergency visits.
- Hospitalization – Medical treatment that requires being admitted to a hospital. Plans may limit coverage for extended stays.
- Pregnancy, maternity and newborn care – Medical services for mother and baby before, during, and shortly after birth.
- Mental health and substance abuse disorders including behavioral health treatment
- Prescription drugs – The federal government has created a list of approved drugs and plans must cover at least one in each category. Drug costs must be counted towards out-of-pocket caps on medical expenses.
- Rehabilitative and habilitative services – Medical services to recover from an injury or treat a chronic condition. Please note that there may be a cap on the number of visits allowed by the plan.
- Laboratory services – Includes diagnostic testing, testing to gauge effectiveness, and some preventative screenings.
- Preventative and wellness services and chronic disease management – Medical services such as counseling, physicals, vaccines, screenings.
- Pediatric services including oral and vision care – Dental care, vision care, well-child visits, vaccinations, and immunizations. Dental and vision care must be offered to children through the age of 18 (2 routine dental exams; 1 yearly eye exam with corrective lenses).
If you have a health plan that you purchased as an individual or as a part of a small group, your plan must include coverage for these Essential Health Benefits with no annual or lifetime dollar limit.
If you have questions about your health plan or need assistance with a denied claim, please contact Kantor & Kantor to request a FREE consultation. We can be reached at (818) 886-2525 or via our online contact form.