Are you planning to buy health insurance through one of the state health insurance marketplaces that open this fall? If so, know what your plan will cover.
The Affordable Care Act (ACA), the federal health care reform law also known as Obamacare, requires that all plans sold in these health insurance marketplaces, known as exchanges, include "essential health benefits" in 10 categories.
Experts say this requirement will help to keep consumers well -- and ensure they get the care they need when they're sick. "To do that, you have to have a broad range of categories covered," says John Rother, president and CEO of the National Coalition on Health Care.
What are the Obamacare 10 essential health benefits?
Here's an overview of the 10 covered benefits and what they mean for you.
1. Preventive and wellness services.
One goal of the ACA is to keep patients healthy, says Christine Barber, a senior policy analyst for the nonprofit Community Catalyst, which offers support to community health organizations. So, all plans -- including those sold in the exchanges -- must offer preventive care from in-network providers with no cost sharing, even when patients haven't met their deductibles. These free services include: routine exams, immunizations, blood pressure and obesity screening for adults, sexually transmitted infections (STI) counseling for sexually active adolescents and adults, mammograms for women over 40 and colorectal cancer screening for adults over 50. Barber says, "This encourages people to go to the doctor for preventive visits -- which can save money, because you're catching problems more quickly, and also save lives."
2. Doctor visits and other outpatient care.
"This is the most basic form of care -- it's what enables you to go see your doctor," Rother says. This category includes visits for almost any medical problem -- from a cough to a sprained wrist to stomach pains. Having this coverage will encourage patients to seek medical care for a problem before it gets bad enough to require an emergency room visit, says Sally McCarty, senior research faculty at the Georgetown University Health Policy Institute. For example, if you have a sore throat, she says, "You won't be as likely to skip the doctor visit and try to treat it at home."
3. Emergency services.
If you do have an urgent medical problem, such as chest pains or a broken arm, you can rush to the ER knowing your care will be covered. Individual health insurance plans have typically included emergency services, such as ambulance rides and ER visits, but insurers sometimes have denied claims on the grounds that the health problem was not an emergency, McCarty says. But the ACA states that if the average person -- not, for example, a doctor or nurse -- goes to the ER for an ailment, insurers have to cover the visit, McCarty says.
If you have a medical problem that requires getting admitted to a hospital -- for example, appendicitis, pneumonia or cancer -- your insurance plan must cover your stay. Individual plans typically cover hospitalization already, experts say, but the cost can add up quickly, exceeding dollar limits that had existed in the past on some skimpy plans. In addition, the ACA bans caps on per-illness and lifetime coverage.
5. Prescription drugs.
Patients who need prescription medications, from antibiotics to blood pressure pills to chemotherapy, will get coverage through plans sold on the exchanges. Now, many individual plans lack prescription drug coverage, so patients have been forced to go without, pay out of pocket or apply to drug manufacturer compassionate use programs, McCarty says. Requiring plans to cover prescription drugs will help patients and save money, Rother says, as drugs can also prevent ailments such as high blood pressure from developing into more serious, expensive conditions, such as a heart attack or stroke.
6. Laboratory services.
Lab work is an important part of routine care from infancy through adulthood and plays a big role in diagnosing and treating many medical conditions, according to LabTestsOnline.org, a website of the American Association of Clinical Chemistry. Laboratory services, such as routine blood work, urinalysis or biopsy, will be covered by plans sold on the exchanges.
7. Maternity and newborn care.
Most individual insurance plans currently on the market exclude maternity care, McCarty says. And, insurers also have often charged women of childbearing age much higher premiums than others pay, McCarty says. But plans sold in the exchanges must cover maternity care, such as regular check-ups, ultrasounds, immunization, nutrition counseling, delivery and newborn care. "Most families want to have good coverage when they're having a baby," Rother says.
8. Mental health services.
Plans sold on the exchanges will have to cover mental health services, including counseling and substance abuse treatment. This type of treatment has been excluded from many individual plans -- and this is an area where lack of treatment can seriously exacerbate a problem and lead to expensive hospitalizations, according to Rother. "If you intervene earlier, it's much less expensive," he says.
9. Rehabilitative and habilitative services and devices.
The ACA requires that plans sold on the exchanges cover services such as physical therapy, occupational therapy and speech therapy, Barber says. Rehabilitative services typically involve helping a patient get back a function lost or compromised by illness, injury or surgery, whereas habilitative services entail teaching a patient a new skill, she says. While the ACA bans lifetime or dollar-limit caps on essential health benefits, insurers may place time limits or other restrictions on these benefits.
10. Pediatric services.
Plans sold on the exchanges have to cover pediatric services, including oral and vision care. The inclusion of dental care will do a lot to keep children healthy, McCarty says.
"If there's ever an area where preventive care makes a huge difference in the long run, it's this," McCarty says.
Are all Obamacare health plans created equal?
But just because the categories are covered, that doesn't mean that every plan will cover any specific item within the category. For example, certain brand-name drugs or specific services might not be covered by some plans, Rother says. That's because the ACA doesn't specify how the plans in each exchange must meet the requirement to cover each category. Instead, each state had to choose a so-called benchmark plan -- in many cases, the largest small-group plan in the state -- to serve as a model for what plans sold in the exchanges cover, Barber says.
"What is covered is going to vary a lot by state," she says.