01/13/2014
Essential Health Benefits Under The Affordable Care Act
ObamaCare (or the Affordable Care Act) has iluenced headlines since the opening of the new Health Insurance Marketplace in October. Surrounded by controversy, misconception and technical defects, the many favorable modifications that ObamaCare delivers to health care have been neglected in the rearrangement. One such change prevails to the sorts of services that are included in health insurance plans: Beginning January. 1, 2014, all health insurance schemes rendered to individuals or to employers with 50 or less employees to be covered under the package of Essential Health Benefits.
Covered Benefits
If the benefits of your plan are applied to the item or service then a health maintenance expense is said to be “covered”. In contrast, your plan benefits are not applicable if an expense is uncovered, that is, you will have to bear 100% of the costs. In another case, there might be 100% coverage of the service. The coverage depends on the item or service and on the health insurance plan. There are variations in the covered benefits from one policy to another.
Four Tiers or levels of Coverage
Controlled by the Affordable Care Act, beginning in 2014, for the health insurance schemes there will be four levels of coverage labeled after the names of four metals as mentioned below.
• Bronze plan = 60%
• Silver plan = 70%
• Gold plan = 80%
• Platinum plan = 90%
The four tiers are distinguished on the basis of their actuarial values or the average of health care costs that will be borne by the plan. The higher the level (i.e. Gold and Platinum), more will be paid by the plan towards your health maintenance expenses, but your monthly premiums will also be high. Irrespective of the kind of plan you have, coverage will be provided to you by some common set of Essential Health Benefits in the year 2014.
The following ten general categories must be covered in the minimum under essential health benefits:
Ambulant patient services – It includes the care received by you at a doctor’s clinic, office or a surgery center without getting admitted to a nursing home. It also involves home health services and hospital services. (Note: some schemes may limit the insurance coverage to 45 days only).
Emergency services – Circumstances like sudden illness or accidents need immediate treatment. These are the cases of emergencies which includes urgent need of an ambulance. You cannot be punished for not being in contact or for not taking any prior permission.
Hospitalization – Care received by you as a patient in a hospital, including attention from doctors, other staff, expenses of all the tests, medications, and room. It also includes coverage for surgeries, transplants and skilled nursing facilities. (Note: some plans may set the coverage for skilled nursing facility for 45 days only).
Laboratory services – Tests conducted to diagnose the underlying disease, or extent of an injury, illness or any other problem, or to check the response of a course of treatment.
Pre-natal and Post-natal services - Care received by women during pregnancy, all over the labor period, delivery and after delivery, and medical attention needed for the newborns.
Psychological disorders and addiction treatment - Inhospital and home care is provided to diagnose and treat a patient with a mental disorder or a substance addict disorder (note: some plans may confine the coverage to 20 days a year).
Rehabilitative Services and devices - Rehabilitative services and devices to help the patient recover their mental and physical skills, which were lost due to any disability, injuries or a chronic condition
Pediatric Services including oral and eye care –‘Well-child’ visits, vaccines and immunizations. Dental and eye care for children under 19.
Prescription drugs – One or more prescribed drug or medicine must be covered in each category of Government approved drugs.
Preventive Medical services and chronic diseases cure - Preventive medical care, like tests, immunizations, cancer screenings etc. are invented to prevent or detect specific medical conditions. Also, care for chronic problems are covered, like asthma and diabetes.