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Affordable Care Act 101: Our Nation’s New Health Insurance Plans

The major parts of the Affordable Care Act will become effective on January 1, 2014.  The heart of the law (passed in March, 2010) calls for ten mandatory services (called Essential Health Benefits) that must be in all new health insurance plans for individuals and small employer plans (under 50 employees) sold by participating health insurance companies.

These ten benefits are:

1.  Outpatient Care – most health insurance plans have covered this type of care.  This type of care typically starts with a visit to doctor’s office, a clinic or same – day surgical center. Home care and hospice care services are also covered.

2.  Emergency Room Services – also covered by many health plans in the past.  Some plans have charged higher out of pocket expenses if the hospital has been out of the patient’s network.

3. Hospitalization – major expenses for inpatient (overnight) care can occur during a stay in a hospital.

4. Preventive, wellness visits and chronic disease treatment – includes screening for blood pressure, cholesterol and colorectal cancer.  Well woman visits are also included.  Preventive care visits have no co-payments.

5. Maternity and Newborn Care – care before and after your baby is born.  If a woman gave birth to a premature baby who required care in an intensive care unit for three months, medical costs can easily exceed $1 million in a large city hospital.

6. Mental and Behavorial Health Treatment – includes treatment for mental health condition  as well as drug and alcohol problems.  There are co-payments and the number of therapy visits may be limited.

7. Prescription Drugs – Medications will be covered for an illness or treatment like high blood pressure. There will be coverage for at least one prescription drug for each category of federally approved drugs.

8. Laboratory Services – The law requires that 100% of preventive tests like breast cancer screening must be covered at no cost.

9. Pediatric Care — dental and vision care services plus well-child care, vaccines and immunizations must be included in plan coverage for children under age 19 for the first time.

10. Rehabilitative Services and Devices — these services will help you gain or recover mental or physical lost due to an accident or chronic condition. Health plans will provide 30 visits for either physical or occupational therapy or chiropractor visits.

Other ACA Information

Several million Americans got letters from their health insurance companies in the fall, 2013 that their health insurance plans would end on December 31, 2013.   These letters were sent out because their health insurance plans did not contain one or more plan services that are now required under ACA.

Most uninsured Americans must enroll in health insurance to avoid paying a penalty to the IRS. ACA offers four health insurance plans if you do not have health insurance through your employer. These plans are commonly called the four “metal” plans – bronze, silver, gold and the platinum plan plus a catastrophic plan for people under age 30.  These plans are based on a percent of how much each plan will cover of medical expenses:

…Bronze, expected to cover 60% of your medical expenses

…Silver, expected to pay 70% of your medical expenses

…Gold, expected to pay 80% of your medical expenses

…Platinum, expected to pay 90% of your medical expenses

All four plans will contain the same ten Essential Health Benefits as noted above.   They will differ on the amount of out of pocket expenses.  Bronze plans have the lowest premium and the highest out of pocket expenses and Platinum plans having the highest premium and lowest out of pocket expenses.

Individual insurance companies are not required to offer all four plans and will have different premiums for the same metal plans.  States may also require that carriers offer plan benefits beyond the above ten Essential Health Benefits.   Some insurance companies will only offer in network plans (using their contracted doctors and hospitals) and others will have both in network and out of network plans.  Check to see if your preferred doctor(s) and local hospital are available to you.  Preexisting conditions can no longer be used to deny health insurance coverage.

The success of the new health insurance program will depend on key factors in 2014 and 2015.   How does the American public view the law over the next 1-2 years? How many people will enroll in these plans?  How many young people (ages 21 to 35, mostly healthy) will enroll? Will there be continuing improvements in the performance and effectiveness of the federal government’s web site (healthcare.gov) to interface accurately with the public, insurance companies and multi-government agencies?  Will there be changes in the ACA law in the next two years?  Future blogs will cover more information about the ACA plans.

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