Under the Affordable Care Act (Obamacare), major medical plans and qualified health plans are required to meet the Minimum Essential Coverage. Basically, a healthcare expense is covered if the benefits of your plan are applied to the service or item. If it is not covered, then you will be fully responsible for the cost. You may still be responsible for the cost or a portion of it even if your expense is covered by your insurance policy, however, the amount you pay will count toward your deductible.
The covered benefits vary from one policy to another. Some policies may cover chiropractic care with a copayment of let’s say, $25 while another might not cover it at all and you will have to pay out of pocket. Generally speaking, the more comprehensive a medical insurance plan, the more expensive it will be.
4 Tiers of Coverage
Under Obamacare, which began in 2014, there are 4 tiers of coverage namely:
- Bronze (60% actuarial value)
- Silver (70% actuarial value)
- Gold (80% actuarial value)
- Platinum (90% actuarial value)
The Minimum Essential Coverage Standard requires major medical plans and QHPs to meet the 60% actuarial value, or the percentage of total average costs covered by the plan benefits. That means for the basic plan, your insurer will shoulder an average of 60% of the covered medical expenses and you will be responsible for the remaining 40% until such time you reach your out-of-pocket or cost-sharing limit.
The higher the level (ie Platinum and Gold), the more the plan will pay towards your medical expenses but it also means your monthly premiums will be higher (compared to Silver and Bronze).
10 Essential Health Benefits
Non-grandfathered health plans or those that did not exist before March 23, 2010 in the individual and small group markets are required by the Affordable Care Act to cover at least the following Essential Health Benefits:
- Outpatient care – The care you receive without being admitted to a medical facility.
- Emergency services – This includes trips to the emergency room (by ambulance).
- Maternity and newborn care – Care before and after childbirth (prenatal care, labor, delivery, post-deliver and newborn baby care).
- Substance use and mental health treatment – This includes counseling, psychotherapy, behavioral health treatment for both inpatient and outpatient care.
- Prescription drugs – These are doctor-prescribed medications for the treatment of a condition or illness.
- Services and devices for rehabilitation – Rehabilitative services and devices needed to help you recover from a physical or mental injury, including speech-language pathology, occupational therapy, physical therapy and others.
- Pediatric services – This covers vision care and dental care for kids, well-child visits, vaccines and immunizations.
- Laboratory services – Testing that will help a doctor diagnose an illness, injury, or condition or monitor the progress of a particular treatment. Preventive screenings and exams are also covered.
- Hospitalization – Care received as an inpatient, including medical procedures, laboratory tests and medications received during the duration of confinement in a hospital.
- Preventive and wellness services – Physicals, immunizations and screenings are covered as well as treatment for chronic conditions like diabetes and asthma.
There are specific health care benefits that vary from state to state and health plans within the same state can also have minor differences.