ACA: ESSENTIAL HEALTH BENEFITS (ESBs) Flashcards
WHAT ARE ESSENTIAL HEALTH BENEFITS?
tHE aFFORDABLE cARE aCT SPECIFIES THAT ALL PRIVATE INSURANCE COMPANIES MUST COVER AT LEAST TEN CATEGORIES OF BENEFITS; THESE ARE CALLED ESSENTIAL HEALTH BENEFITS. eACH STATE DECIDES THE SPECIFICS OF COVERAGE, SO EXACTLY WAHT FORM YOUR COVERAGE IN EACH OF THESE CATEGORIES TAKES DEPENDS ON WHERE YOU LIVE AND WHICH INSURANCE COMPANY YOU PICK.
ARE ALL HEALTH PLANS REQUIRED TO PROVIDE THE 10 ESSENTIAL HEALTH BENEFITS?
No. If you belong to a large group plan or a plant that’s grandfathered into the system, these plans aren’t required to carry essential health benefits. (Small group health plans and individual health plans must provide the 10 Essential health Benefits.)
Any plans that do carry EHB must remove annual and lifetime dollar amounts for those services.
EHB: Abulatory Patient Services
If you visit your doctor’s office for a visit and aren’t admited toa hospital, this is the kind of care you’re receiving (“ambulatory” means you can walk ou of the office under your own poer). It also refers to home health and hospice care, though in these cases coverage may be limited to proty-five days. however, if you go to a neighborhood clinic, your doctor’s office, or a same-day surgery center, those services are covered.
EHB: Emergency Services
Under the ACA you cannot be penlaized for going out-of-network or not having prior authorization if you go to the Emergency Room. If you jor your family find yourself in circustances in which a condition, if not immediately treated, will lead to serious disability or death, the ACA protects you from higher copayments and coinsurance if you wind up in an out-of-network ER.
ESB: Hospitalization
This is among the most potentiall expensive healthcaare you can receiv. It includes room and board in the hospital, as wll as physician and nursing care, tests, drugs, and a lot of other miscellaneous charges. It also covers surgeries,, transplants, and care you receive in a skilled nursing facility (such as a nursing home). Not that some plans limit skilled nursing facitliy coverage to fort-five days. The insurance company does not pay the entire bill. Depending on your plan, you may still be responsible for 20 percent or more of the bill – more if you haven’t reached your out-of-pocket limit. Since some hospitals charge as much as $3,000 per day for room and board (and that doesn’t include the medical stuff), hospitalization can take a big bite out of your wallet.
EHB: Maternity and Newborn Care:
This EHB refers to care that women receive during pregnancy, birth, and pot-delivery, as well as care for the baby itself. ACA says that prenatal care must be privded without extra cost, but some other services will probably require a charg. For instance, insurance plans under ACA must provide breatfeeding support, counseling, and equipment for the duration of breastfeeding, but the specifics of what’s covered may be different from plan to plan. Yur doctor will determine what kind of breastfeeding plan you need, and most insurance plans will follow the doctor’s recommendations. In some caes, yu may need preauthorization, Under ACA, most insurance plans will cover the cost of a breast pump (either rental or ours to keep). Ask if the plan provides guidance as to whether the pump can be manual or electric, how long the coverage lasts, and where you can get the pump.
Other services in this category of EHB taht may be offered by various planse include:
- Testing for sexually transmitted diseases
-
RH blood typing and antibody testing
- Folic acid supplements, which help protect your baby from certain birth defects
- A wide range of prenatal test, including anemia screening, UTI screening, and screening and help to quit tobacco use
-Testing for gestational diabites
- Birth control after the birth of you baby
Be sure to check you plan that it covers these items before your doctor prescribes them or adminsters the tests.
EHB: Mental Health and Substance use Disorder Servidces, Including Behavioral Health Treatment.
One in four adults, or about 61 million people in the United State, experiences some form of mental illness in a give year. About 13.7 million have serious illnesses such as schizophrenia, major depression, or bipolar disorder. Even greater numbers suffer from drug abuse. TJhe ACA mandates coverage of inpatient and outpatient services for such disorder, though some planse may limit this to 20 days per year. These services must provide evaluatiion, diagnosiis, and treatment. This is another instance in which exactly what will vary from state to state.
EHB: Rehailitative and Habilitative Services and Devices
If you have sustanined an injury, yoiu’ll probably need some sort of physical therapy to regain the functionality you’ve lost. In general, insurance plans must cover at least thirty visits a year for occupational, phyyysicl, chiropractice, speech, or cardiac therapy and pulmonary rehabilitation. As well, the plans, must cover devices such as canes, wheelchairs, and crutches that will be needed while the therapy is in progress.
- Habilitative services are services that allow you to acquire a functional skill you should have but don’t because of sickness or injury (instance, speech therapy for an autistic child). Things are a bit less clar with long-term disease treatment such as multiple sclerosis, and you’ll need to check with your plan to find out the extent of its coverage.
- Rehabilitative services are services that allow you to get back a skill you lost because of illness or an injury. For instance, if you’ve suffered a stroke, you’ll needphysical or occupatiional therapy to regain motor functions.
EHB: Laboratory Services
To come up with an accurate diagnosis of your ailment and the appropriate treatment, your doctor conducts all sorts of test. The ACA mandates insurance plans to cover laboratory teest; however, it’s up to you to fnd out the scop of this coverage – what tests are covered, which laboratories, and what physicians canprescribe laboratory work. If you doctor recommends a lab that isn’t oulined in your insurance plan, ask the plan provider if there’s replacement or it they anticipate accepting that lab in the future.
EHB: Preventive and Wellness Services and Chronic Disease Management
Not all illnesses and conditions go away after a single treatment or even a series of treatments. Some can last a very long time – even a lifetime. This EBH includes anyting from annual physicals to immunizations and cancer screenings designed to prevent or detect certain medical conditions, as well as assist in the care and managemnt for chronic conditions such as asthma and diabetes.
EHB: Pediatric Services
If you’re wondering how your children will fare under the Affordable Care Act, the answer is, pretty well. Children under age nineteen are entitled to get their teeth cleaned twice a year, as well as receivex-rays, fillings, and medically necessary orthodontia. Children under age nineteen are also enitltled toan ey exam and one pair of glasses or set of contact lenses a year. In addition, insurance plans must cover well-child visits and recommended vacines and immunizations. Remember that you will have to have a plan that cover your family if you want your child to have coverage (A spose can also be coverd under a family plan.)
EHB: Prescriptions
The ACA mandates that Marketplace plans must cover at learst one drug in every category and class in the U.S. Pharmacopeia, the official publication that lists approved medications. In addition, pharmaceutical costs are counted toward out-of-pocket caps on medical expenses, as opposed to separate caps as some companies used to do.
