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Health

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Associated Press

KEY PROVISIONS

An overview of some of the key changes to health care services under the Affordable Care Act:

Essential benefits

Under the law, health insurers must cover 10 essential benefits. This will make health plans costlier but also more comprehensive.

Starting next year, the rules will apply to all plans offered to individuals or through the small-group market to employers with 50 or fewer workers. The essential-benefits requirement does not apply to plans offered by larger employers, which typically offer most of these already.

The 10 benefits are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; management of chronic diseases, and preventive and wellness services; and pediatric services, including dental and vision care.

People will be able to pick from insurance plans with differing levels of coverage and varying costs for co-pays and premiums. But insurers will have to cover a certain percentage of the services’ cost.

Dental, vision

Dental and vision care are considered essential benefits for children 18 and younger whose parents or guardians get insurance coverage through the individual or small-group plans.

States can choose to offer those items as standalone plans, and federal subsidies would not help pay for the costs. The law does not mandate this coverage for adults.

Pre-existing conditions

Starting in 2014, most plans – whether obtained through an employer or on the marketplace – cannot deny coverage or charge more money because of pre-existing health conditions.

But if you have what is known as a grandfathered individual plan – a plan you buy yourself that was in existence before March 23, 2010, and has remained unchanged – then this rule would not apply.

Dollar limits

Under the law, the amount of money people will have to pay out-of-pocket each year for medical and prescription drug costs will be capped at $6,350 for individuals and $12,700 for a family.

These limits are separate from the monthly premiums people pay. The limits take effect in 2014 for those buying insurance on the state health insurance exchanges.

For those with employer-based coverage, the restrictions will be fully in place in 2015.

In addition, most insurance plans will be prohibited from setting lifetime dollar limits on coverage for essential health benefits. This means your insurer cannot deny you coverage because your medical bills have gone over a certain amount.

Age 26

One popular provision of the health care law already is part of most insurance plans – allowing young people to stay on their parents’ insurance plans until age 26.

This also covers dependents, including stepchildren, adopted children and some foster children.

This benefit will be required of all plans that provide dependent care. Starting in 2014, younger people can remain on a parent’s or caregiver’s plan even if they have an employer option of their own.

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