Part II: Ten Essential Health Benefits Covered in 2014

Creative Commons image by duncan via Flickr

Dear Concerned Friend,

In the first part of my response, I shared the PCIP health insurance option for your pregnant and uninsured friend. There is also good news for others who lack employer sponsored insurance, including your friend’s husband. His health needs, unlike those of his wife who is expecting, are likely less time-sensitive but equally as important.

Currently, people searching for coverage outside their jobs and in small businesses can have a hard time finding coverage that meets their needs. For example, it’s often hard for a woman to purchase a plan with maternity benefits on the individual market. Similarly, health insurers sometimes don’t cover mental health benefits for these types of policies. As a result, many people find themselves in the same position as your friend’s husband: self employed but uninsured.

Here is the good news: If he chooses to buy health insurance in 2014, his insurance plan will be subject to the Essential Health Benefits (EHB) rule.  The EHB rule of the Affordable Care Act mandates that all health insurance plans for individuals and small businesses cover 10 categories known as the Essential Health Benefits. These benefits will include coverage that most people would want in a plan.

With the health reform, all policies for individuals or small groups must cover the following 10 EHBs:

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

Did you see where it said “maternity and newborn care?” Awesome. If your friends decide to have another child in 2014, mother and baby will be covered by the EHB rule!

As you can see, it will be harder for insurers to hide behind loopholes and small type, and that’s good news for the consumer in general, and for folks like your friends, in particular. People trying to make it either by taking employment without benefits, or as a small entrepreneur, will have a better shot at success with access to affordable coverage, thus protecting them from catastrophic medical costs should they become ill, have an accident, or get pregnant.

Dear Concerned, thanks for being a good friend. Having a new baby is a big life change by itself and these new parents will likely need your caring and support. I hope this helps!

To a well and healthy Texas,
Cheasty Anderson

Posted in The Texas Treatment|Tagged , , , , , |

2 responses to “Part II: Ten Essential Health Benefits Covered in 2014”

  1. Erin Carter says:

    I am in the same boat. My husband is an optometrist and works for a small practice and we have to buy individual health insurance. We are still paying for our 2nd child bcs we didn’t have maternity coverage. Here is my question….we are planning to try for baby # 3 in the fall of 2013. If I deliver in 2014 will maternity be covered or do I need to wait until 3014 to get pregnant so that it is covered?

    Thank you!

    • AnatKelman says:

      Dear Erin,
      The ACA requires all health insurers that sell in the individual and small employer markets to include Essential Health Benefits in their coverage “effective for plan or policy years beginning on or after January 1, 2014.”

      What this Means for You:
      Should you decide to keep the policy you have today, and assuming your policy runs on a calendar year (meaning it renews each January), you will have access to all essential health benefits, including maternity and newborn care, starting January 1, 2014. If your current policy does NOT renew each January (say it renews each year in August, for example) you should be able to just cancel it for December 31, 2013 and buy a different policy that DOES take effect January 1, 2014 and covers maternity.

      The good news is that you’ll be able to start comparing policies and begin the enrollment process through “the Exchange” in October of this year for any new coverage that would become effective on January 1, 2014.

      Bottom Line:
      If your plan starts to cover maternity on January 1, 2014, but you had pre-natal care before that day, your plan won’t go back and cover your 2013 pre-natal care. But, it will pay for covered pre-natal and maternity/delivery services in 2014 and beyond.

      Hope this helps and best wishes!

      -The Texas Well and Healthy team

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