While the debate continues over the pros and cons of the Affordable Care Act (ACA), the truth is that the Act is law and beginning on January 14, 2014, it will greatly expand health care benefits to more than fifty-five million Americans who for a long time had no healthcare insurance and to millions of others who were underinsured.
The ACA defines certain standards by which the health insurance companies must abide which mandate that they offer health plans that provide essential health benefits.
These essential benefits include:
Ambulatory Patient Services
This is outpatient care which is the common form of health care. This is when a patient walks into their doctor’s office, gets treated, and walks out. Nearly all healthcare insurance plans cover this now, but how much they pay, who their members can see, network providers, can vary. The ACA says the network size be a sufficient size.
This is a big one. Many, but not all, plans offer prescription drug coverage, but it is typically at an additional cost. Under the ACA all small-group and individual plans will cover at least on drug in every class and category in the U.S. Pharmacopeia, which is the official publication of approved medications in the U.S.). In addition, drug costs will be counted toward out-of-pocket caps.
When an individual must go to the Emergency Room for a serious and sudden condition, such as a stroke or heart attack, this visit is typically covered. There is no preauthorization needed under the ACA, and out an of net-work charge cannot be charged to the individual.
Mental Health Services
There are currently many health insurance plans that either do not cover or only partially cover mental and behavioral health services. This changes under the ACA. Mental and behavioral health will be billed by session, but will be covered.
Under the ACA, health insurers are required to cover hospitalizations. They may require the insured to pay twenty percent as out-of-pocket costs if they have not reached their annual out-of-pocket cap. With some hospitals charging as much as $2,000 per day for just room and board, these expenses can grow quickly.
Rehabilitative and Habilitative Services
The ACA requires health insurers to cover both rehabilitative therapies as well as habilitative therapies (sometimes including alcoholism treatment plans). These include services to help an individual overcome long-term disabilities.
Preventive and Wellness Services
This is the service many experts believe can help reduce rising healthcare costs in the U.S. The ACA requires health insurers to cover fifty preventive services.
The ACA requires certain preventive tests be covered, but other tests can still be billed individually. Costs for these can range from twenty dollars for a lab test to thirty percent for an MRI.
The ACA requires healthcare insurance providers to cover teeth cleanings twice annually for children under 19 years of age, as well as fillings, x-rays, and orthodontia that is medically necessary. Additionally, these children will also get one free eye exam and one pair of contacts or glasses annually.
Maternity and Newborn Care
The ACA requires all prenatal coverage at no extra cost and requires the health insurer to cover the childbirth and newborn infant’s care as well.
For many in the United States, the benefits defined under the ACA are welcome and provide much needed health coverage. What remains in question is how much will this cost and will the right combination of individuals sign up so that the program will pay for itself as the designers have planned. These things remain to be seen, but the ACA is changing health insurance in the U.S.