Essential Health Benefits-What Do You Want vs. What Are You Willing To Pay?

The Affordable Care Act requires Americans have access to quality, affordable health insurance. To achieve this goal, the law requires health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges (Exchanges), offer a comprehensive package of items and services, known as “essential health benefits.”  Essential health benefits must include items and services within at least the following 10 categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management, and
  10. Pediatric services, including oral and vision care

The challenge now facing the Colorado Department of Insurance is what additional, if any, benefits they will require the new policies to contain. Each state is empowered to devise their own list.

Here is a partial run down of additional requirements being consider in other states and of course, each benefit has a very active advacacy group pushing for inclusion:

Acupuncture (now a requirement in California)

Chiropractic care

Pre-vacation visits to travel clinics (whatever this is, apparently it will be required in Colorado)

Fertility treatments

Speech therapy

Bariatric Surgery (stomach reduction)

Each of these services is, of course, very dear to a segment of the population. The question before the Department of Insurance is “is it reasonable to require all health insurance policy holders to pay higher premiums for these benefits, when they may or may not be “”essential””?

Here is an excellent article written by the Washington Post on this subject.

Read more
No Comments

Child-Only Health Insurance Policy

One of the most impactful regulations of the Affordable Care Act (Obamacare) that has already gone into effect is the requirement that no child under 19 may be turned down for health coverage. For the family with a child with a significant ”pre-existing condition” this is a godsend. For the insurance companies it is a headache.

The reason that this is difficult for the insurance companies, is that although they can “rate-up” the child’s portion of the premium up to 200%, some of these kids have conditions that may cost $100,000′s to treat

Another concern is that parents, knowing the insurance companies must cover their child, will not be willing to purchase and pay for coverage until the child is “literally in the ambulance on the way to the hospital.”

While a parent and child may apply anytime for insurance, to ameliorate this situation somewhat, the feds have allowed the insurance companies to only offer child-only policies during ”open enrollment” periods, except in the case of a “qualifying event.” In Colorado those open enrollment periods are January 1-31 and July 1-31 with coverage starting 30 days after the enrollment period.

Outside these periods, the only other times insurance companies are required to offer child-only coverage is in the case of a qualifying event. A qualifying event is defined in the new Colorado law as within 30 days of birth, adoption, marriage, dissolution of marriage, loss of employer-sponsored coverage, loss of eligibility for Medicaid or Child Health Plan Plus (CHP+), entry of a valid court or administrative order mandating the child have coverage, or involuntary loss of existing coverage other than because of fraud, misrepresentation or failure to pay premium.

A carrier may deny coverage if the child has access to other creditable coverage such as a parent’s plan through an employer.

Most health insurance carriers will offer only one of their plans to child-only applicants. These plans are usually bare-boned and are difficult to apply for, i.e. paper applications, no agent involvement, etc. The only company we work with in Colorado that offers their full array of plans, and no additional barriers in applying, is Rocky Mountain Health Plans.

Of course, we expect this will all change on January 1, 2014 with the full implementation of the Affordable Care Act and the exchanges that go with it.

If you’d like to know more about child-only policies, please call me at 303-541-9533.

Read more
No Comments