What is covered under the new Affordable Care Act (Obamacare) health plans?
The new standardized health insurance plans that qualify to be included in the Health Care Marketplace and for premium subsidies are divided into 4 categories — Bronze, Silver, Gold, or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members.
The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn’t the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.
In addition to the Metal Plans, one other option, called a Catastrophic Plan, is available for single people under the age of 30, or people who qualify through financial hardship. Catastrophic Plans cost less money, but have fewer benefits. They include preventive benefits, but don’t cover as much when you are sick. And they usually have high deductibles.
Required Coverage For All Qualifying Health Plans*
The Affordable Care Act (“ACA” and also frequently referred to as “Obamacare”) requires health plans to cover certain “essential health benefits.” Beginning in 2014 individual and small group plans will have to include the following health benefits unless the plan qualifies as grandfathered.
- Ambulatory patient services – These include outpatient services such as doctor visits.
- Emergency services – These include care received in an Emergency Room
- Hospitalization – These include medically-necessary surgeries and other inpatient procedures
- Maternity and newborn care
- Mental health services
- Substance use disorder services – These services include behavioral health treatment
- Prescription drug coverage
- Rehabilitative and habilitative services and devices – Rehabilitation covers services such as relearning to walk after a stroke. Habilitative services involve learning a new skill such as a speaking without a speech impediment.
- Laboratory tests and services
- Preventive and wellness services as well as the management of chronic diseases
- Pediatric services (including both oral care and vision care)
*See specific policies for coverage, limitations & exclusions