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These are the 10 Categories of Services Health Insurance Plans Must Cover Under the Affordable Care Act
All the plans offered in the Marketplace cover the same set of essential health benefits. Every health plan must cover the following services under the affordable care act. This also includes private health plans sold to individuals and families.
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services or emergency care.
- Hospitalization (like surgery and overnight stays)
- Pregnancy,maternity and new born care (both before and after birth)
- Mental Health and Substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs- Check your summary of benefits with carrier.
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventative and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits) Must buy those separate.
Plans must also include the following benefits:
- Birth control Coverage
- Breast Feeding Coverage
Common Healthcare Plan Questions
What is group health insurance coverage?
Are all employer group health insurance policies the same?
Health insurance is regulated in each state. Therefore, the laws regarding health insurance offered by the different types of employers can vary significantly from state to state. However, with the implementation of the Affordable Care Act (ACA), the federal government also regulates health insurance.
Different types of employers may offer different benefit plans. Millions of Americans work for small employers, which for health insurance purposes are generally those with 50 employees or less. Millions of other Americans get their health insurance coverage through large employers. Generally, those are businesses with more than 50 employees. The laws about how coverage can be issued to large groups are different than those for small groups, and the way that premium rates are determined is also different. Have 50 or more employees? you will want to learn about the fines with the affordable care for not offering insurance to your group.
What are the coverage requirements for small employer plans?
The Affordable Care Act requires that insured small group plans offer health plans that meet certain benchmarks. The benchmarks are represented by the metal levels of platinum, gold, silver and bronze. Each metal level tier plan is designed to provide the same average level of benefit to an enrollee.
The tiers are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members: • Platinum plans are the most generous and more expensive. These are designed to pay as much as 90% of medical expenses. The best you can possibly get. Very few companies offer Platinum health plans. • Gold plans are designed to pay 80% of medical expenses. • Silver plans are expected to pay 70% of medical expenses • Bronze plans are expected to pay 60% of medical expenses.
Can I be turned down for a Health insurance?
What is the difference between a Private health plan “Off exchange plan” and a Government subsidized health care Plan aka “On exchange plan”?
People who qualify for subsidies may be enticed into buying from the exchanges But if your plan isn’t from the exchange, you won’t get your tax credits as a subsidy. Health insurance companies such as Aetna, Humana and UnitedHealthcare have opted not to participate in exchanges in some marketplaces. Companies such as Select health and blue cross in certain states are still selling on and off exchange.
The second reason why people buy a private plan over a subsidized plan with Obamacare is that you have a greater choice of doctors and companies to choose from with in the private market. The prices are virtually the same. Also you don’t have to deal with the long process of showing your income at healthcare gov. With a private health plan, your policy in most cases will be issued same day.
What is a Co-payment?
What is a Deductible?
What is co-insurance?
Let’s use this example, if your health insurance plan has a 20% coinsurance requirement (and does not have any additional co-payment or deductible requirements), then a $100 medical bill would cost you $20, and the insurance company would pay the remaining $80. Here is a tip. Remember to look at your out of pocket maximum or OOP cost also. Some plans range from $2500 to $25000. An out-of-pocket maximum is the most you’ll have to pay during a policy period (usually a year) for health care services.
What Does the Term “Out of Pocket Maximum” Mean?
Open Enrollment for 2017 Health Plans Starts November 1, 2016. When are the Deadlines to Enroll in Obamacare?
• December 15, 2016: Last day to enroll in or change plans for coverage to start January 1, 2017. • January 1, 2017: 2017 coverage starts for those who enroll or change plans by December 15. • January 31, 2017: Last day to enroll in or change a 2017 health plan. After this date, you can enroll or change plans only if you qualify for a qualifiying event.
Tip: Apply early and call your health insurance agent to get tips and tricks to get your plan issued early.
What is a Special Enrollment Period and Do I Qualify for One?
Job-based plans must provide a special enrollment period of at least 30 days.
Here is a basic list special life events.
There are 4 basic types of qualifying life events. (The following are examples, this not the full list.) • Loss of health coverage • Losing existing health coverage, including job-based, individual, and student plans • Losing eligibility for Medicare, Medicaid, or CHIP • Turning 26 and losing coverage through a parent’s plan • Changes in household • Getting married or divorced • Having a baby or adopting a child • Death in the family • Changes in residence • Moving to a different ZIP code or county • A student moving to or from the place they attend school • A seasonal worker moving to or from the place they both live and work • Moving to or from a shelter or other transitional housing • Other qualifying events • Changes in your income that affect the coverage you qualify for • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder • Becoming a U.S. citizen • Leaving incarceration (jail or prison) • Ameri Corps members starting or ending their service
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