Under the Affordable Care Act (ACA), consumers may access new health care coverage that includes coverage of preventive care services. Many of our new insurance products are designed to cover a core set of essential health benefits. A quick summary of health care coverage and services that may affect your patients is listed below.
Annual Dollar Limits
Generally, ACA prohibits group health plans and insurers that offer health insurance coverage from imposing annual limits on the dollar value of essential health benefits. This provision is effective for plan/policy years beginning on or after Sept. 23, 2010. Grandfathered individual market policies are exempt from this provision. However, ACA and federal regulations indicate that, for plan/policy years beginning before Jan. 1, 2014, a plan or coverage may establish restricted annual limits on the dollar value of some essential health benefits.
Beginning in Jan.1, 2014, ACA places cost-sharing limits on non-grandfathered small group plans. Small group plans may not have a deductible higher than $2,000 for individuals and $4,000 for families.
ACA makes health insurance more widely available to dependent children. This provision requires group health plans and insurers that offer health insurance for dependent children to make coverage available for children (married or unmarried) until age 26.
Essential Health Benefits
Certain health benefits that are deemed "essential" must be offered by non-grandfathered individual plans and non-grandfathered fully insured small group plans both on and off the exchange in 2014. No lifetime maximums or annual dollar limits are allowed on these 10 essential health benefit categories as defined by a benchmark plan selected by the government beginning in 2014:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Habilitative and rehabilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
Grandfathered Health Plans
A grandfathered health plan is a group health plan or health insurance coverage that was in effect (and had at least one individual enrolled) on March 23, 2010, and has not made certain changes since that date to cause a loss of grandfathered health plan status. Some of ACA requirements do not apply to grandfathered health plans.
Lifetime Dollar Limits
ACA prohibits group health plans and insurers that offer health insurance coverage from imposing lifetime limits on the dollar value of essential health benefits. This provision is effective for plan/policy years beginning on or after Sept. 23, 2010. For plan years beginning on or after Jan. 1, 2014, group health plans may not establish any annual dollar limits on essential health benefits.
Beginning Jan.1, 2014, individuals cannot be denied coverage because of a pre-existing condition. ACA protects these individuals from having to pay higher rates or have benefits limited to exclude these conditions.
ACA requires non-grandfathered health plans and policies to provide coverage for preventive care services without cost-sharing (such as coinsurance, deductible or copayment), when the member uses a network provider. Services may include screenings, immunizations, and other types of care, as recommended by the federal government.
A list of preventive care services can be accessed from the Department of Health and Human Services (HHS) website.
Women's Health Benefits
With the coverage provided by ACA, a number of new preventive services for women may be covered with no cost-sharing on or after Aug. 1, 2012, when using a provider in their plan/policy network. These services include:
- Well-woman visits
- Screening for gestational diabetes
- Testing for Human Papillomavirus Virus (HPV) in women at least 30 years old
- Counseling for sexually transmitted infections
- Screening and counseling for Human Immunodeficiency Virus (HIV)
- U.S. Food and Drug Administration (FDA) approved contraception methods and counseling
- Breastfeeding support, supplies and counseling
- Interpersonal and domestic violence screening and counseling
- Contraceptive coverage