In 2014, the Affordable Care Act made 10 “Essential Healthcare Benefits” (EHB) mandatory, no matter the size of the company you work for or your healthcare provider. These requirements are set to come online in 2017.
Importantly, healthcare plans must be balanced among the 10 categories, namely,
- Outpatient care (care you get without being admitted to a hospital)
- Trips to the emergency room
- Treatment in the hospital for inpatient care
- Care before and after your baby is born
- Mental health and substance use disorder services
- Prescription drugs
- Services and devices to help you recover if you are injured, or have a disability or chronic condition
- Lab tests
- Preventive services
- Pediatric services
Your insurer can substitute benefits within each category, but cannot substitute one of the main categories, and it can change coverage, such as a benefit’s duration. Finally, under the EHB, your plan cannot discriminate against you because of your age, disability or your expected length of life. Here is some greater detail about the services that must be included.
Ambulatory patient services. These are the services that you likely use the most, since they cover your regular doctor’s visits. Most plans, regardless of your company’s size, usually cover this service.
Laboratory services. The new law requires that healthcare insurers cover preventive tests like Pap smears for women and prostate exams for men. However, your insurance coverage can bill other types of diagnostic, so check to see what is covered on Employee Compensation Reports.
Prescription drugs. The EHB mandates that all healthcare plans now cover some prescription drugs. All plans must now cover at the minimum one drug in every category and class of medications approved for use in the United States. And, when you pay for prescriptions the cost must be applied to your annual out of pocket expenses.
Maternity and Newborn Care. This new requirement entitles all mothers and babies healthcare before and after the baby is born since prenatal care is preventive care, so it must be given at no additional cost.
Emergency services. Your coverage extends to trips to the emergency room. EHB allows you to get emergency services even out of network with no extra fees. And, your plan can no longer require that you get preauthorization before you seek emergency services.
Hospitalization. This new requirement means your healthcare insurance must cover inpatient treatment for any serious medical concern. It does not mean, however, that you are exempt from paying a copay which can be quite expensive if you are still under your annual out of pocket limit.
Mental health and substance use disorder services. Perhaps this is one of the most extensive additions required by the EHB that is laid out in the Employee Compensation Reports. Your healthcare plan must include behavioral health care, substance abuse, and mental health coverage on par with that of the plan’s physical health benefits.
Rehabilitative and habilitative services and devices. Your plan likely already covers rehabilitation therapies like pain relief or learning to walk again, and cover equipment like wheelchairs. However, now habilitative services must also be covered, which are therapies that help with long-term disabilities like Parkinson’s disease.
Preventive and wellness services. These services include things like vaccinations, counseling and screenings that help to prevent more serious illnesses.
Pediatric services (including oral and vision care). Under EHB, now all children under the age of 19 can get dental and vision services, including one pair of glasses every year.
It’s important for employees to know what benefits they receive. Savvy employers use Employee Compensation Reports, like those from COMPackage.com, to highlight the total compensation an employee receives. After all, you can’t appreciate what you are getting if it’s not clearly spelled out. No one knows what changes the new administration will make, but such changes take time, so the aforementioned may be valid for a while to come.