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Health Care Reform:

Health Insurance & Affordable Care Act

Essential Benefits and Health Reform

Starting in 2014, new private insurance plans must cover a core group of benefits, called essential health benefits. These services are similar to those in a typical employer plan -- and in some cases better.

10 Benefits New Plans Should Cover

1. Addiction treatment and mental health care

2. Care for children. This includes:

  • All essential benefits
  • Dental care
  • Eye doctor visits

3. Doctor visits

4. Emergency care

5. Hospital care

6. Lab tests

7. Medicines your doctor prescribes

8. Physical, occupational, and speech-language therapy. These services help you get back on your feet after a serious injury, surgery, an event like a stroke, or because of a long-term health problem.  This care can also help you overcome a disability, like a speech problem. Coverage includes:

  • Therapist visits
  • Tools, called durable medical equipment, like braces or a wheelchair

9. Pregnancy and maternity/childbirth care

10. Preventive care and treatment for chronic illness.  This includes:

Note: Essential benefits might end up a little different in each state. States can exchange an essential benefit for one of equal value.

Will Your Plan Cover Essential Benefits?

For health plans taking effect in 2014,

You will get these benefits if:

  • You are buying individual or small group insurance, which is for a company that has fewer than 50 full-time employees.
  • You are going to receive Medicaid for the first time.

Your health plan may not cover the benefits if:

  • You have a "grandfathered" plan. This is a plan that was already in place before the Affordable Care Act was signed into law on March 23, 2010.  
  • Your plan is self-insured. Large employers sometimes run this type of plan. They act like a health insurance company, collecting premiums and paying medical claims themselves.
  • You have large, group health insurance through work, usually if your company has more than 100 workers. This kind of plan may not provide all 10 essential benefits.

If your insurance plan at work doesn't cover essential benefits and you want to get them, ask your employer if it offers a plan that includes them.

Limits on Essential Benefits

Which treatments for back pain are covered under the essential benefits? How many times can you see a physical therapist?  There will still be some limits on what your insurance company will pay. Here are rough guides to those limits:

Your state sets a benchmark plan. For now, each state decides which services, tests, and tools all of its private plans must cover.  To do this, each state chooses a typical employer plan to use as a model, called the benchmark plan.

If the benchmark plan covers in vitro fertilization or autism treatment, for instance, your plan will, too. If the benchmark plan doesn't cover these, your plan may still cover them, but it doesn't have to.

Check out your state's benchmark plan at the federal government's CCIIO web site.

Your health plan can limit visits. You may only get help paying for a set number of doctor visits, hospital days, or prescription refills each year. Check the fine print in your plan's summary of benefits.

Your health plan cannot cap the cost of care.  Each year and over your lifetime, your plan cannot put a dollar limit on covered essential benefits. So if you have a serious or chronic illness, you won't go broke trying to pay your medical bills.

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