The Affordable Care Act (ACA) was designed to make the public responsible for their own health insurance decisions. The ACA also regulated what all individual policies have to cover. (Remember, employer plans may be different.) All ACA-compliant individual insurance plans must cover the ten essential benefits. They are:
1. Ambulatory patient services (outpatient care like going to your local doctor)
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. Preventative and wellness services and chronic disease management
10. Pediatric services
The level to which these items are covered can be found on your summary of benefits. Knowing how to read your summary of benefits is also a part of the education process the government is hoping will happen.
Non-compliant plans will not include maternity, preventative or mental health service and usually will require either a health exam or health questions on the application. If you are asked any health questions when applying, IT IS NOT COMPLIANT. Non-compliant plans may also exclude certain conditions or not cover any pre-existing conditions.
Starting in 2019, there will no longer be a government penalty for having a non-compliant health insurance plan. The most popular non-compliant options currently in our area are plans from Tennessee Farm Bureau, faith-based sharing plans (such as Medi-Share) and short-term medical plans intended to cover gaps in coverage.
With this easing of the penalty for non-compliant plans, I believe we will see more non-compliant plans pop up. In this case, "Buyer Beware" applies. Be sure you know exactly what you are buying. What does it cover and what doesn't it cover? A good question to ask would still be "Is this plan ACA compliant?" If it is not, ask "Why not?"
I hope this helps and, as always, if you have questions call or email me.
