The Essential Health Benefits have been released by the federal government. This dictates that Insurers must cover 10 broad categories of care. This includes maternity services, doctor and medical services, mental health and substance abuse, and prescription drugs.
Why is this important?
All individual and small group will be effected by this ruling. This document is 149 pages long. Even Medicaid will have to cover the essential benefit.
Out of pocket max will be dictated to all health plan even self funded. For an individual the out of pocket max can not be more than $6,250 and for family $12,500. In 2014 you will not be able to get a policy that has a higher out of pocket. This could have a big impact on a lot o plans.
There has been a large amount of individual plans sold online, that have a higher out of pocket. Those plans will have to comply with the new rule or you could pay a penalty.
The benefits does allow people to get drugs that are needed but not on the drug formulary. So if you need a certain cancer drug then you should be able to obtain it. This is viewed as a positive thing.
The best news, is that insurance companies cannot charge for colonoscopy even if a polyp is found. This has been one of the most frustrating coverages for Hoosiers. You go in to have a colonoscopy and it is covered at 100% by the insurance plan, under preventive care. Then the doctor finds a polyp and now you have a diagnosis code and a bill for $1,200. So under the law the entire procedure is coverage at 100% with no cost to the insured.