A Guide to New Health Insurance Benefits

Here's a rundown of the medical care you're now entitled to receive.

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In the last few months, the media have been consumed with the struggles surrounding the rollout of health insurance exchanges under the Affordable Care Act. While much of the focus has been on policyholders being dropped from their current policies or the difficulties in navigating exchange application forms, less time has been spent on what Obamacare means for those already insured or those who have successfully signed up for a health plan. 

One of the key provisions of the ACA establishes minimum standards for all health plans bought or created after March 23, 2010. The changes in insurance standards include guarantees that prevent insurance carriers from dropping policyholders if they become sick or made a mistake on their applications. Additionally, the ACA bans price discrimination based on race, gender or pre-existing conditions and allow children to stay on their parents' insurance plan until age 26. 

The ACA also requires insurance companies to spend at least 80 percent of all insurance premium dollars on medical care. And insurers will not be allowed to set annual or lifetime caps on “essential benefits,” which include:

•  ambulatory patient services
•  emergency services
 hospitalization
•  maternity and newborn care
 mental health and substance use disorder services
 rehabilitative services and devices
•  preventive and wellness services and chronic disease management

•  pediatric services

There are many other provisions of the law that will significantly change the way you find and pay for health care. By understanding them, you will be better prepared to make informed choices about your health management.

Choice of doctors

The ACA gives policyholders the right to choose their primary care provider from their health plan's provider network. The law also allows policyholders to use a participating obstetric or gynecological specialist of their choice without the need to first get a referral from their primary care provider. This will encourage doctors and hospitals to compete with each other for patients, which may ultimately lower health care costs. 

Before the ACA, many insurers would not pay for emergency services outside of their networks or would require the policyholder to receive "pre-clearance" before billing the emergency service to the insurer. This created a large problem for emergency situations – the last thing a person in a car accident wants to think about is whether or not the nearest hospital accepts his or her insurance policy. However, the ACA now bans insurance providers from charging a higher copay or disqualifying payment for out-of-network emergency care.

Summary of coverage

Before the ACA, many policyholders simply didn't know what their policies covered. Insurance providers were required to disclose the nature of the policies sold, but they rarely did so in simple language, and coverage limits typically were hidden in legal and medical jargon. Under the ACA, all policies must have an easy-to-understand and short summary of the health plan's benefits and coverage as well as a glossary of terms used in health insurance and medical care. A plan’s summary also must be made available to health insurance shoppers before applying for the plan.

Free preventive care

The ACA requires all plans created or purchased after March 23, 2010 to offer – at no additional cost or copayment – network-provided preventive services, including:

 adult and childhood immunization vaccinations
 HIV screening for everyone ages 15 to 65
 obesity screening and counseling
•  diet counseling for at-risk adults
 alcohol misuse screening and counseling
 Type 2 diabetes screening for adults with high blood pressure
 sexually transmitted infection prevention counseling for at-risk adults 
 well-woman visits for women under age 65
 osteoporosis screening for at-risk women over age 60
 breast cancer mammography screenings for women over age 40

 vision screening for all children

The complete list of no-cost preventive services is available at healthcare.gov.

 
Regulatory compliance with the ACA has forced some insurance providers to change or cancel out-of-compliance policies. It is important to take the time to learn if your policy conforms to these ACA standards and, if necessary, how to obtain an incompliance policy. Those Americans who hold a noncompliant insurance plan will be subject to the Obamacare penalty.