Don’t miss Dr. Robert L. Barbieri’s October article titled “Gynecologic care across a woman’s life”
Insurance reforms end lifetime limits on coverage
Insurance reforms are important to us and our patients. The better the private health insurance system works—allowing us to provide our best possible care to patients and making sure they can see us when they need our care—the less our nation relies on the public safety net.
Beginning in 2010, the ACA eliminated all lifetime limits on how much insurance companies would cover when beneficiaries get sick; it also bans insurance companies from dropping people from coverage when they get sick. So if your patient has private health insurance and has faithfully paid her premiums and hasn’t committed fraud, her insurer cannot drop her or impose a limit on her coverage once she claims benefits.
This may be especially important for patients who need the most care, such as those who have cancer or another long-term, expensive, and unforeseen diagnosis. Because of this provision, you will not have to worry about your patient losing coverage in the middle of a long course of treatment.
The insurance practice of charging women more than men for equivalent policies ended on January 1, 2011, making insurance more affordable for our patients. Insurers in the individual and small group markets are allowed to vary premiums only for age, geographic location, family size, and tobacco use, not for gender—another important aspect of the law.
2014 is a key year in health reform
Exchanges begin
In 2014, under the ACA, state health insurance exchanges become reality.
An exchange is a marketplace where people can shop for health insurance; private health insurers can market their insurance products in state and multistate exchanges if they comply with new federal insurance reforms established in the ACA and offer the minimum benefits packages established by each state. Exchanges are intended to offer patients a choice of health insurance plans that are affordable, comprehensive, and easy to compare. Low-income individuals will be able to purchase private insurance in the exchanges with the federal premium subsidies or tax credits.
Insurers wanting to market their policies in an exchange may not deny coverage for preexisting conditions, including pregnancy, domestic violence, and previous cesarean delivery. They can’t deny coverage on the basis of an individual’s medical history, health status, genetic information, or disability. And they can’t impose waiting periods longer than 90 days before coverage takes effect, including 9-month waiting periods before maternity coverage.
Essential benefits are established
The ACA sets a minimum standard of health-care coverage that must be included in nearly every private insurance policy. The intent is that every person in the United States, regardless of where they live, who employs them, and what their income is, should have access to the same basic care.
Effective January 1, 2014, all insurance plans, except plans that existed before the ACA was enacted on March 23, 2010, must offer an “essential health benefits” (EHB) package, which must include:
- ambulatory patient services
- emergency services
- hospitalization
- maternity and newborn care
- mental health and substance use disorder services
- prescription drugs
- rehabilitative and habilitative services and devices
- laboratory services
- women’s preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care.
Last December, HHS surprised many by giving states flexibility to design their own EHB packages, as long as the packages included each service on the list.
To choose its EHB package, a state must select a “benchmark” plan from the top- selling plans in four markets: federal and state public employee plans, commercial HMO plans, and small business plans. If a state doesn’t select a benchmark plan, the EHB defaults to the largest small-group market plan in the state. Each state must also choose an EHB package for its Medicaid program using the same 10 benefit categories.
State EHB plans must follow ACA requirements on annual and lifetime dollar limits but may impose limits on the scope and duration of coverage.
As for state-mandated benefits, if a state selects an EHB package that does not include a benefit already mandated by the state, the state must fund coverage for that service on its own—a decision HHS has promised to revisit in 2016.
Abortion decisions reside with the states
ACA requirements regarding abortion coverage 1) take effect in 2014 and 2) apply only to private health insurance plans marketed in the state exchanges that 3) cover abortions beyond those eligible for Medicaid coverage now, which are those that involve cases of rape or incest or that are necessary to save the life of the mother. Medicaid coverage for these categories of abortion is allowed under the Hyde Amendment.