Plan Changes from Health Care Reform

When shopping for a health plan, you will be pleased to know that plans must meet certain requirements under the health care reform law:

  • Essential health benefits are offered by most plans, no matter where you purchase the plan. Essential benefits cover doctor’s visits, hospital stays, preventive services, prescription drugs, mental health services, and other health care services.
  • Coverage for pre-existing conditions must be provided. The health plan can’t charge you more or refuse coverage if you have a health condition such as diabetes, heart disease, or high blood pressure.
  • Many preventive care benefits must be given to plan members at no charge (when delivered by a network provider). These health care services and certain immunizations help keep you and your family healthy.
  • No annual or lifetime limits on your plan benefits. The lifetime limit is prohibited for plans issued after September 23, 2010, and annual limits will phase out as of 2014.
  • Certain consumer rights and protections must be offered by most health plans. You will receive easy to understand plan details so you know about the coverage you are getting. And if you get sick, you’re protected from getting your health insurance canceled because of your illness (but it can be canceled if you don’t pay your premiums). Plus, you can ask for an appeal if a health plan denies payment for a service.

Standard Plan Choices

Starting in 2014, health insurance plans are required to meet guidelines that standardize health plan choices for consumers. This will help make it easier to compare the health plans and the benefits each one offers.

To participate in state and federal exchanges, an insurance company must offer plans that fit within four levels of coverage, which are referred to as “metal” plans: Bronze, Silver, Gold, and Platinum. A carrier doesn’t have to offer plans in each level, but it must offer at least one Silver and one Gold plan.

Essential Health Benefits

All plans must provide coverage for a set of minimum essential health benefits that include services and items in these 10 categories:

  • Outpatient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive, wellness, and chronic disease services
  • Pediatric services, including oral and vision care

Levels of Service

While each plan must cover the same scope of benefits, the value of these benefits may vary across the plan levels. For example, Bronze plan premiums will cost less, but the plan will offer the least generous coverage with more out-of-pocket expenses. A Platinum plan will have higher premiums but will offer more coverage with lower deductibles, lower co-pays, etc.

Plans are measured using an “actuarial value” that compares what percentage of health costs are covered by the plan. The chart below gives you an idea of how the actuarial values are applied to different plan levels.

Level Actuarial Values
Plan Level Insurance Covers You Pay
Bronze 60% 40%
Silver 70% 30%
Gold 80% 20%
Platinum 90% 10%