Managing the Cost of a Chronic Condition: FAQ
Wondering how health reform affects what's covered and what you'll pay? Here are some answers.
Will my health insurance help pay for managing a chronic condition?
Most likely. All plans sold in the Marketplace, on the individual market, or through small employers must cover a list of essential health benefits, a rule that's part of the Affordable Care Act. The exception is grandfathered plans. Grandfathered plans are health plans that existed before the Affordable Care Act was signed on March 23, 2010, that have not substantially changed. Large employer health plans are not required to cover the essential health benefits, but most do.
- Doctor office visits
- Lab tests
- Prescription medicines
- Preventive care
- Behavioral health services
- Rehabilitation, including physical therapy and occupational therapy
- Hospital care
Will any plan that covers essential benefits cover the same things?
Not necessarily. Each state can make decisions about what's covered. For each benefit, states decide what specific services and level of care the plans will cover. Each health plan for sale on the state's Marketplace must cover at least what the state chose.
Here are a few ways benefits can vary between states:
- How many medicines they cover in a specific drug class. One plan may cover many medicines to lower high blood pressure , and another will only help pay for a few.
- Only some plans cover bariatric surgery , infertility treatment , or acupuncture .
Look closely at the summary of benefits for any health plan you think you may enroll in.
How much of the costs for doctor visits and other care will my health plan cover?
That depends on what plan you choose and the specific design of the plan.
Your health plan has to limit the amount it charges you for your benefits. For plans bought through the state Marketplaces, you don't pay more than $6,600 for a single person and $13,200 for a family in 2015. Large employer plans have those same limits in 2015.