A sobering look at the 10 essential health benefits covered under ACA,
and whether you can manage without them
by Michael Mahoney Mr. Mahoney is senior vice president for consumer marketing with GoHealth, a health insurance and healthcare technology firm in Chicago. Visit gohealth.com
In the United States, a 15 minute, nine-mile ambulance ride could cost over $1,700. Treating pesky spring allergies with Nasonex could cost $108. And replacing an Asthma inhaler could cost over $175.
This is just a glimpse into the world of being an uninsured American. But thanks to the Affordable Care Act, all health plans are now required to cover 10 Essential Health Benefits, including ambulance rides, prescription allergy medication, and inhalers.
This means that if you have health insurance, at least part of the costs of these benefits will be covered. Many Americans rely on these benefits to stay healthy – and it’s clear that without insurance, they can be extremely expensive.
For example, chronic illness treatment is now covered as part of the 10 Essential Health Benefits. Nearly 50 percent of Americans suffer from at least one chronic illness. So without the Affordable Care Act and chronic illness coverage, half of the country – individuals battling diabetes, arthritis, and Alzheimer’s – could face incredibly high medical bills and struggle to get treatment.
Although the 10 Essential Health Benefits are now covered with no annual limits or lifetime maximums, many Americans might not know what these benefits include. Now is the time to learn about the 10 Essential Health Benefits and take advantage of your health plan.
The average length of a hospital stay in 2010 was almost 5 days and could have cost more than $4,000. That’s a lot of time to wonder whether or not your visit is covered. Thankfully, coverage today includes room and board, care from all hospital staff, and medications and lab tests throughout your stay. Nursing home care, surgeries, and transplants are all covered, too.
2. Emergency services
In 2010, there were over 130 million emergency room visits in the United States. Unfortunately, trips to the emergency room can happen to anyone and are often extremely unpredictable. Now under the Affordable Care Act, emergency room visits do not require pre-authorization, and you cannot be charged extra for out-of-network visits.
3. Pediatric care
The main focus for most parents is their child’s wellbeing and good health. If you’re worried that a visit to your child’s pediatrician for the sniffles or the chicken pox won’t be covered, there’s no longer reason to worry. As outlined by the Affordable Care Act, dental and vision must also be covered for all children under age 19.
4. Prescription drugs
Can you imagine paying $176 for Cymbalta to treat your anxiety? What about $162 for Celebrex to treat your arthritis? That’s how much you could pay for those prescription drugs without insurance. However, if you have insurance, at least some of your prescription drug costs will be covered as part of the 10 Essential Health Benefits.
5. Prenatal and maternity care
Facing an emergency C-section is almost always out of the patient’s control. Many times, choosing whether or not to have one is a matter of life and death. The fact that the average cost of a C-section without insurance could be up to $15,000 could drive many women to reconsider growing their family. Now that an Essential Health Benefit category comprises prenatal and maternity care, C-sections – as well as contraception, well woman visits, and newborn care – are all covered.
6. Laboratory services
Lab tests are often required if you’re looking for an official diagnosis, but without coverage, they can be extremely expensive. The Affordable Care Act requires that fees associated with lab tests be covered, so now there’s no excuse to forgo that blood test. Breast cancer screenings and prostate exams also fall into this category.
7. Outpatient care
This is one of the most common forms of health care. You head in to your doctor’s office or clinic, get treated for your condition, and leave right after it’s complete. Covered services include wellness and prevention, treatment, diagnosis, and rehabilitation. Outpatient care also includes hospice and private home care.
8. Preventive and wellness visits
Avoiding the doctor because a visit might not be covered? This is not only unsafe, but it’s now also untrue. Certain preventive services are now completely covered under the Affordable Care Act as an Essential Health Benefit. These services include vaccines, obesity counseling, and depression screenings. Remember: it’s important to see your doctor before you get sick, not after you’ve been diagnosed.
9. Mental and behavioral health treatment
Before health reform, it was difficult for many Americans to get the mental and behavioral health treatment that they needed. Anyone can be touched by mental illness at any given time, often taken by surprise. Although there may still be a stigma associated with mental illness, individuals can no longer be denied coverage for the treatment that they deserve.
10. Services and devices to help those recovering from injury, or those with a disability or chronic illness
Many plans in the past have covered necessary treatment for a broken arm or a fractured wrist. But coverage for something like physical therapy to treat multiple sclerosis has proved to be much more difficult. However, the Affordable Care Act now requires coverage for equipment and services to help anyone with a chronic illness or disability maintain a standard of living.
Don’t yet have coverage? Enrolling in a health plan means you’ll be guaranteed coverage should you need medical care, like vaccines for your toddler or an unexpected trip to the emergency room. If you choose to forgo coverage, you’ll not only be responsible for the high cost of your medical care, but you’ll also face a hefty tax penalty for going uninsured. It pays off to get covered and avoid facing these costly consequences.