Choosing the best health insurance plans for aging family members can be daunting, but worry not. The Affordable Care Act established Essential Health Benefits (EHB) as standard covered services for many plans. Learning EHB details helps caregivers pick suitable coverage.
The Affordable Care Act (ACA), commonly known as Obamacare, is a comprehensive healthcare reform law enacted in March 2010 in the United States. Its main goal is to help more Americans access affordable health insurance, improve the quality of care, regulate the health insurance industry, and reduce healthcare spending in the US.
The ACA introduced several mechanisms to increase insurance coverage and affordability, including mandates, subsidies, and insurance exchanges. Additionally, it includes provisions to expand Medicaid, support medical care delivery methods designed to lower health care costs generally, and mandate the inclusion of essential health benefits in specific health plans.
Since 2014, all new individual and small-group health insurance policies must cover essential health benefits for all enrollees. This includes policies sold in the ACA's health insurance exchanges and off-exchange.
Essential Health Benefits (EHB) are ten categories of services covered by health insurance plans under the Affordable Care Act (ACA). These benefits are intended to make sure that health plans offered in the individual and small group markets, inside and outside the Health Insurance Marketplace, provide a comprehensive package of items and services.
Insurers cannot place annual or lifetime limits on covered services. If you're caring for a loved one who needs ongoing medical care, you won't have to worry about running out of coverage.
However, the number of covered visits can still be a cap. For example, your insurance plan may cover up to 20 yearly doctor visits. If you're looking for health insurance for yourself or your loved one, make sure you're getting a plan that covers essential health benefits and doesn't have any annual or lifetime caps.
Specific medical care falls under "essential" status, meaning health plans must include these services at no added cost. Besides setting coverage minimums, EHB ensures individuals access treatments supporting essential health and wellness. Categories include:
All non-grandfathered health plans reimburse emergency department visits in medical crises without prior authorization. These plans provide urgent lifesaving care when seconds count.
Rehab focuses on regaining lost function, while habilitation helps patients develop skills never fully acquired developmentally. Examples include physical, occupational, and speech therapy for those facing intellectual/physical disabilities.
Plans cover well-baby visits and nursery charges for mother and child after delivery. Newborn care also includes screening tests checking for various medical conditions.
Access to necessary medications is critical for your loved one's health. At least one medication per drug class, including insulin, is covered. Different options help family caregivers find affordable therapies, such as generic, brand name, specialty, and biosimilar medications. Work with your loved one's healthcare provider to find the best medication for their needs and budget.
Outpatient/office visits, procedures, tests, and services not requiring overnight hospital admission are covered. These range from minor treatments like flu shots to MRI scans diagnosing complex conditions.
Care for psychiatric issues like depression/anxiety falls under essential benefits, as do substance abuse disorders. Both outpatient counseling and inpatient treatment qualify when medically necessary.
Diagnostic labs analyzing bodily fluid/tissue samples inform prevention plus acute and chronic condition management. Routine bloodwork, culture testing for infections, and genetic screens fall under this category.
Child beneficiaries through age 21 should undergo developmental assessments, immunizations, preventive counseling, and medical treatments without additional fees.
Autism care incorporates behavioral analysis and therapy addressing symptoms for optimal functioning. These evidence-based interventions teach critical social and life skills to children qualifying based on developmental testing.
Annual well visits, counseling for improved health literacy, chronic disease education, and immunization recommended by the CDC help patients safeguard their well-being. Family history evaluations also identify inherited risk factors.
While essential health benefits form critical foundations, caregivers should compare supplemental offerings when selecting policies for aging loved ones. Plans can include extra coverage like vision, dental, hearing services, and more to meet unique needs.
For example, Medicare Advantage policies add routine dental, vision, hearing, and wellness benefits to fill gaps in original Medicare. Private insurers also craft plans with care coordination programs assisting those facing multiple chronic conditions. Caregivers would benefit from such support in navigating convoluted systems.
Even small perks like gym memberships promoting physical activity or allowances for glasses/contacts make daily life easier on fixed incomes. If loved ones underwent past dental procedures requiring maintenance like implants or bridges, dental plans help afford the required upkeep. Audiology coverage also lowers hearing aid costs, averaging thousands out-of-pocket.
Carefully weigh premium increases against potential savings from added benefits over the plan year. While essential health offerings provide critical medical care, supplemental coverage targets lifestyle factors impacting one's enjoyment of life. Reviewing all available options ensures aging family members receive comprehensive support.
While essential health benefits form critical foundations, optimal plans safeguard the quality of life. Caregivers are pivotal in identifying additional coverage and out-of-pocket costs, balancing affordability with support for emerging needs. Though policies are overwhelming at first glance, the security they provide loved ones grants peace of mind when life's unexpected curveballs strike.
