The health insurance industry has changed tremendously since the implementation of the Patient Protection Affordable Care Act aka “Obamacare”. Over five million Americans had their policies terminated, as they did not meet the standards of the new Affordable Care Act requirement. While the government of the United States referred to them as “junk” plans, many were better and more valuable than what is offered today.
The “Obamacare” plans focus on preventive care. Under the law many of the services are covered without co-pay and not subject to a deductible or co-insurance. The proponents of the law refer to this service a “free”, however, these benefits add cost to the premium so you are paying for it on the front end instead of the back end. Prior to the ACA, plans tended to focus more on the major medical. For example, the Health Savings Account (H.S.A) which was approved by Congress in 2003 and became a law in January 2004, is a High Deductible Health Plan with a savings account attached to it. On these types of plans they realized that the most expensive part of the health plan was doctor visits co-pays and prescription coverage. So these features were removed from the plans and applied to the deductible. You could use the money from the savings account (assuming you funded it) for these services. I personally have had one of these since 2005, originally with a $2600 family deductible and leading up to 2014 a $5200 family deductible. I would be responsible for all charges up to the deductible, after that I was covered at 100%. Now under the ACA most of these type plans fall in the Bronze category and have a family deductible of over $12,000. They cover your preventive care 100%. The problem with this philosophy is most of us could afford to pay $100 or $200 for a physical, but a major claim, such as a heart attack or cancer, and have to spend $12,700, that would cancel a few family vacations.
Insurance rates are a derivative of the costs of the insurance carrier’s claims in relation to the premiums collected. Now that there is no more underwriting it is reasonable to see the insurance carrier’s claims expense going up as they are adding additional risk to their portfolio, which in turn you can see adding to the premium cost. To offset some of this cost, many insurance companies have narrowed their networks of doctors and hospitals. This means you may have to either change doctors or change insurance carriers depending on your plan.
Another part of your insurance plan to be concerned with is the prescription drug portion of the plan. Most prescription drug plans prior to the ACA were a four tier co-pay plan, such as $10 Tier one ( preferred generic) Tier 2 might have been $20 (non-preferred generic), Tier 3 may have been $35 for preferred name brand and tier 4 might have been $100 or a 25% of list price. Sometimes you may have had a separate deductible for name brand medications (Health Savings Accounts were not like this). Now you need to look closely at this part of the new ACA plans. Now many plans will say generic drugs no cost. Tiers two through four might have a co-pay, but after the deductible is met. Most silver and bronze plans utilize the same major medical deductible before you get the co-pay for name brand medications. If you take a drug such as Nexium, which costs somewhere around $400 per month, that would all be applying to your deductible.
In the event you choose to go out of network, the costs get more out of control. This will vary from company to company, but in general if you go out of network on a Preferred Provider Organization (PPO), the deductible and out of pocket expenses double. There are many reasons you may want to go out of network, especially for things like cancer or a transplant. Some hospitals across the country are better equipped to handle certain illness than others, but it will cost you a lot more. Also some services are not covered out of network. In that case you could pay thousands of dollars and not even have it applied toward your out of pocket maximum.
Under the ACA, all plans are required to cover what are called the ten essential health benefits. Most plans prior to that ACA covered seven out of these ten. The other three were, generally speaking, optional. The seven included were outpatient care, emergency room care, hospital care, prescription drugs, recovery services (occupational or physical therapy, psychiatric etc.), lab and blood work. Preventive care was also covered, however, the scope of what is considered preventive has been expanded. Some of these were covered with a copayment, while others were applied to the deductible. The three that were often optional in the individual market were mental health, maternity and pediatric dental. Maternity coverage, if offered, would raise monthly premiums between $100 and $200 per month and often had a 12 month waiting period. Mental health really varied from state to state and plan to plan. Mental health ranges from attention deficit disorder all the ways to schizophrenia. This has been streamlined under the ACA.
Preventive care has been expanded under the new law and these services are covered without co-pay regardless if the plan covers doctor office visits or not. A large change is in how colonoscopies are handled. They were always considered a “covered expense”, but applied to the deductible, now they are covered as all other preventive services. You hear proponents of the law saying you now have “free” preventive care. I would say that the cost is already built into the premium.
Healthcare.gov provides a list of about 26 services that are free to women under the Affordable Care Act. Yes, you read it right – under Obamacare, there are 26 preventive services that women can have done for free as long as they are delivered by an in-network provider. I can’t possibly discuss every single one here, but I feel that there are a few that are definitely worth mentioning.
These services are broken into two broad categories on hc.gov – services for women who are or who may become pregnant and other preventive services. First, we’ll touch on some of the more general benefits available for all women.
General Preventive Services for All Women
Some general preventive services that are covered for women include multiple cancer screenings, including mammograms for breast cancer for women over 40 and cervical cancer screenings for sexually active women. These screenings are always highly unpleasant, so removing the financial burden makes them a little easier to deal with, in my opinion.
Other services include tobacco use screening and interventions, osteoporosis screening depending on age and risk factors, and domestic and interpersonal violence screening and counseling for all women. The list goes on, so I highly recommend visiting healthcare.gov for full explanations of services offered.
ACA Benefits for Women Who Are or May Become Pregnant
First, the ACA requires that FDA approved contraception must be covered by health insurance plans without requiring a copayment. This is personally one of my favorite benefits, because my birth control prescription that my doctor considers to be medically necessary, once cost me $30 a month. I know several ladies who have saved a substantial amount of money thanks to this free preventive services.
I also know several ladies who thrilled that breastfeeding support and counseling from trained providers and access to breastfeeding supplies are free preventive services for women. Also for those who are or who will become pregnant, new health plans must also include maternity coverage. Although not all maternity services will be free, health plans will at least help cover costs associated with pregnancy. A big Obamacare WIN!
Multiple other services are available at no charge, including folic acid supplements for women who may become pregnant, expanded tobacco counseling and intervention for pregnant women who are tobacco users. Again, the complete list, along with more detailed information, is available at healthcare.gov.