Under the law, insurers must cover 10 essential benefits. Starting next year, the rules will apply to all plans offered to individuals or through the small-group market to employers with 50 or fewer workers. The essential-benefits requirement does not apply to plans offered by larger employers.
The covered benefits are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; management of chronic diseases, and preventive and wellness services; and pediatric services, including dental and vision care.
People will be able to pick from insurance plans with differing levels of coverage and varying costs for co-pays and premiums. But insurers will have to cover a certain percentage of the services’ cost.
Need a teeth-cleaning or eye exam? You still could be reaching into your own wallet to cover the cost even after the law takes full effect next year. Dental and vision care is considered an essential benefit for children aged 18 and younger whose parents or guardians get insurance through the individual or small-group plans. The law does not mandate this coverage for adults, but some states could choose to have them covered.
Starting in 2014, most plans cannot deny coverage or charge more money because of a pre-existing health conditions.
However, if you have what is known as a grandfathered individual plan — one you buy yourself that was in existence before March 23, 2010, and has remained unchanged — then this rule would not apply. Check details on your plan and consider shopping around.
Under the law, out-of-pocket costs each year for medical and prescription drugs will be capped at $6,350 for individuals and $12,700 for a family. These limits are separate from the monthly premiums people pay. The limits take effect in 2014 for those buying insurance on the state health insurance exchanges. For those with employer-based coverage, the restrictions will be fully in place in 2015.
In addition, most insurance plans will be prohibited from setting lifetime cost limits on coverage for essential health benefits. This means your insurer cannot deny you coverage because your medical bills have gone over a certain amount.
MIAMI — Dear seniors, your Medicare benefits aren’t changing under the Affordable Care Act. That’s the message federal health officials are trying to get out to elderly consumers confused by overlapping enrollment periods for Medicare and so-called “Obamacare.”
Medicare beneficiaries don’t have to do anything differently and will continue to go to Medicare.gov to sign up for plans. But advocates say many have been confused by a massive media blitz directing consumers to new online insurance exchanges set up as part of the federal health law. Many of the same insurance companies are offering coverage for Medicare and the exchanges.
Medicare open enrollment starts Oct. 15 and closes Dec. 7, while enrollment for the new state exchanges for people 65 and under launches Oct. 1 and runs through March.
“Most seniors worry they’re going to lose their health coverage because of the law,” said Dr. Chris Lillis, a primary care physician in Fredericksburg, Virginia. “I try to speak truth from the exam room but I think sometimes fear dominates.”
Next month, roughly 50 million Medicare beneficiaries will get a handbook in the mail with a prominent Q&A that stresses Medicare benefits aren’t changing. Federal health officials have also updated their training for Medicare counselors, and are prepping their Medicare call center and website.
“We want to reassure Medicare beneficiaries that they are already covered, their benefits aren’t changing, and the marketplace doesn’t require them to do anything different,” said Julie Bataille, spokeswoman for the Centers for Medicare and Medicaid Services.
But she said call centers for the state exchanges are already fielding questions from Medicare recipients and rerouting them to the Medicare line.
Advocates are also warning of scams that may pop up alongside legitimate door-to-door outreach about the Affordable Care Act ramps up and advising seniors not to give out personal information.
Jodi Reid, executive director of the California Alliance for Retired Americans, worries there hasn’t been enough outreach to seniors and that advocacy groups are spending the bulk of their advertising funds targeting those affected by the exchange. Her organization, which represents nearly 1 million seniors in California, is putting together a one-page fact sheet to help dispel myths.