10 essential benefits all insurance policies must carry

By Robin Erb



All new insurance plans — whether sold on Michigan’s state exchange or sold off the exchange — must carry 10 essential health benefits. That means higher costs for many consumers who had leaner policies before the health law, but it also means a higher standard of care.

The 10 essential benefits are:

■ Ambulatory patient services: It includes visits to your doctor’s office, home health care services and hospice care, although some carriers might limit these services to no more than 45 days.

■ Emergency services: Emergency room visits and the transportation to get there must be covered. Plus, you can’t be penalized — as you can under some policies now — for going out of network or for not having prior authorization.

■ Hospitalization: Hospital stays must be covered, though you may have to pay 20% or more of your bill if you haven’t reached your plan’s out-of-pocket limit. Surgeries, transplants and care in a skilled nursing facility also are included, though some carriers may limit the latter to no more than 45 days.

■ Maternity and newborn care: Policies must cover costs for prenatal care, delivery and care for the mother as well as postnatal care. Many plans in the individual market previously excluded this coverage.

■ Mental health and substance abuse services: All policies must provide coverage for both inpatient and outpatient care, though some carriers may limit this to 20 days each per year.

■ Prescription drugs: At least one drug in every category and classification of federally approved drugs must be covered by plans.

■ Rehabilitative and habilitative services and devices: Plans must provide 30 visits per year for either physical therapy, occupational therapy or chiropractor services, 30 visits for speech therapy and 30 visits for cardiac or pulmonary rehab.

■ Laboratory services: Preventive screening tests — including those for prostate exams and breast cancer screenings — must be provided free. You may have to share the cost of other tests, depending on your policy.

■ Preventive and wellness services: Policies must cover dozens of screenings to help prevent chronic disease. Among them is testing for diabetes, colorectal cancer, high blood pressure, depression and HIV for those at risk. Plus, those who are overweight must have access to dietary counseling, and smokers must have access to programs to help kick the habit.

■ Pediatric services: Dental and vision care, previously not covered by many health policies, must be offered to children younger than 19. That means they will be able to get their teeth cleaned twice a year and get X-rays and fillings, for example. They also must be able to get an eye exam and one pair of glasses or set of contact lenses a year.

Source Detroit Free Press