Ten Essential Benefits all ACA Health Plans Must Include.

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Qualified Health Plans offered on the ACA marketplace must all include the same essential benefits*. These are:

1. Emergency Services

2. Hospitalization for surgeries and other inpatient care

3. Laboratory services - such as x-ray, PET scan, MRI, and CAT scans, and blood work)

4. Mental health and substance use disorder services, including behavioral health treatment such as counseling and therapy.

5. Outpatient care

6. Pediatric services - which include dental and vision benefits for those under 18 (Some plans until their 19th birthday)

7. Pregnancy, maternity, and newborn services. Including prenatal, childbirth, and postnatal care.

8. Prescription medications - plans cover most generics and then have varying benefits for name brand, non-preferred and formulary.

9. Preventative care, wellness services such as annual physicals and immunizations, and chronic disease management.

10. Rehabilitative and habilitative services and devices required to help people with an injury, disability, or chronic condition or recover skills.

    
    

    *For more detailed information and benchmarks by state for those operating their own State Based Exchange, click here: https://www.cms.gov/marketplace/resources/data/essential-health-benefits

It’s important for one to become familiar with their own ACA health plan, benefit levels, and how each impacts your out of pocket expense each time you get treatment.

When deciding whether to save on monthly premium and pay a higher deductible and co-insurance, while difficult to consider, think about how an unexpected catastrophic event could impact your family.

All ACA Qualified Health Plans are categorized using “metal” levels, that are currently Bronze, Silver, and Gold in south eastern Virginia. Bronze typically have lower premiums and higher co-pays, higher out of pockets costs on treatment requiring co-insurance, or the portion of a bill you are responsible for, and higher annual deductibles. Silver and Gold plans can have higher premiums with lower out of pocket costs. Typically Bronze plans pay 60%, silver 70%, and gold 80% on treatment requiring you to pay a portion of the bill. Said another way, For a Bronze plan, your portion of co-insurance would typically be 40% of the bill, where Silver and Gold you'd be responsible for 30% and 20% respectably. That’s a simple way to differentiate between the plans. Each plan clearly defines coverage for each benefit category.

One very important point that you'll want to discuss with your agent when considering a high deductible plan is understanding and considering the financial impact it could have on you and your family if you were to get sick and be hospitalized. When coverage says 40% co-insurance after deductible and your deductible is $7,200. Would you be able to absorb paying $7,200 and 40% of your hospital bill? No, me either. Talk to your health insurance agent and ask questions if you don’t understand something before you enroll in a plan.

Next, we’ll talk about what all this means and how it impacts you.