The Affordable Care Act of 2010 was created in response to notable gaps in the healthcare marketplace that left millions of people without coverage or made health insurance too expensive for average Americans to afford. Before the law took effect, health insurance policies often involved a patchwork of benefits that could vary widely, sometimes leaving Americans exposed to high medical bills that resulted in bankruptcy. While some changes should impact the ACA in 2019, the law still retains the 10 essential health benefits that were believed to be necessary for effective healthcare. Not sure what benefits are considered “essential” to major medical insurance? Let’s take a look.
1 – Ambulatory Care
You can receive outpatient care for health issues without having to be admitted to a hospital, and those services are covered under Obamacare. Ambulatory care refers to any time you need to see your primary care physician for something like a bad chest cold, skin rash or minor injury, or a medical provider outside of a hospital setting, such as a dermatologist performing a mole removal in her office. Generally, you’re responsible for a copayment or must fulfill a deductible amount before coverage begins. Cost-sharing – how much you pay for a medical service or treatment – depends on your plan’s cost structure.
2 – Emergency Services
When you have a healthcare emergency, the Affordable Care Act guarantees coverage for medical services. Your health plan may include a network of providers, including hospitals, so choose your hospital carefully if you can. But in a true emergency, your carrier may waive out-of-network charges. Some states even have laws about this, though it’s not a guarantee. In any case, you’ll be required to cover any copays, coinsurance rate or deductibles as outlined in your plan even in an emergency.
3 – Inpatient Hospitalization
The ACA covers inpatient hospitalization when you experience a profound illness or injury that requires treatment, such as surgery or other necessary procedures. Before Obamacare, major medical plans could cap benefits for the year or for a person’s lifetime. That’s not the case anymore. Insurers aren’t allowed to cap benefits, so you won’t need to worry about hitting a benefit cap if you end up with a costly illness like cancer.
4 – Pregnancy, Maternity and Newborn Care
In the past, pregnancy and maternity care might have been excluded from coverage under private health insurance policies, which created a significant financial burden on families. Labor and delivery are expensive. Under the ACA, prenatal care and care for new mothers is covered, along with coverage for newborn children. This includes care for regular checkups throughout pregnancy as well as hospitalization for labor, delivery and postnatal care. Newborns are also covered during the postnatal period.
5 – Mental Health Care & Substance Abuse Care
Coverage for mental health care hasn’t always been a given with major medical plans. Under current law, insurance companies cannot exclude you because of a pre-existing mental health condition, nor can they charge you more for your premiums. Plans vary in what they cover, but you’ll have access to mental health care – inpatient and outpatient – thanks to requirements under the law. Substance abuse treatment is also covered under the ACA, which is especially useful in light of the nation’s alarming opioid epidemic.
6 – Rehabilitative Services & Devices
Because recovering from a medical condition may require rehabilitative programs and special equipment, the ACA also includes these as part of the essential health benefits. These services include physical therapy, speech and language therapy, occupational therapy and psychiatric rehabilitative care to help people return to normal function after an accident or disease. ACA healthcare coverage also offers coverage for rehabilitative devices, such as wheelchairs, neck braces and prosthetic limbs.
7 – Prescription Drug Coverage
Under Obamacare, health insurance policies must offer prescription drug coverage. The amount of coverage can vary from one plan to another, varying on the types of drugs and the degree to which certain types are covered, both name brand and generic. If you need regular medications, check health plans carefully for prescription benefits to make sure they cover what you need.
8 – Laboratory Services
The ACA also covers laboratory services and diagnostic testing, such as tests for diabetes, HIV, anemia and high cholesterol. Other tests may include medically necessary X-rays, MRI tests, biopsies and tissue analyses. Your plan will require different cost-sharing amounts depending on the service and how it’s billed. Preventive screenings, such as cholesterol tests, may not cost anything out of pocket while a CT scan could require you to cover 30 percent of the bill.
9 – Pediatric Care
Major medical policies cover pediatric care as well, which includes dental and vision coverage for children under age 18. Wellness checks, trips to the doctor for the flu, scheduled immunizations and urgent care visits are just some of the many benefits that fall under the pediatric care category.
10 – Preventive Care
The Affordable Care Act considered preventive services an essential coverage that helps people avoid illness and/or manage disease. The goal in covering these services without any cost-sharing is to help reduce healthcare costs. People who manage their health tend to avoid higher costs down the road. Preventive care includes annual checkups, immunizations, flu shots and screenings for a variety of diseases, such as cancer. Regular care to manage health problems like diabetes, heart disease or kidney disease are also covered.
Major medical coverage isn’t the only kind of health insurance available, but it is the most comprehensive. If you have a chronic condition, you need regular medications, you have a family with young children or you just like the option of full benefits, consider a major medical plan first for your healthcare needs. Open enrollment runs from November 1 through December 15, so explore your options today.