Under health reform, coverage will depend on where you live

After the Affordable Care Act goes fully into effect in 2014, all individual and small-group plans will have to start covering a set of "essential health benefits" that are only partially spelled out in the law. The law left the job of filling out the details to regulators in the Department of Health and Human Services, and we've just found out how they're going to do it.

They're going to toss the ball to the states, which means that if you live in California your "essential benefits" may be slightly different then if you live in, say, Louisiana. For instance, 15 states, including California but not Louisiana, require small group plans to cover infertility treatments like in-vitro fertilization.

In most states, if you buy your coverage on the individual market, your coverage is likely to be more comprehensive than it is now. For instance, according to statistics provided by HHS, 62 percent of people in individual plans don't have maternity coverage today. After 2014, they all will.

The reform law says that all plans must cover, at a minimum, the following categories: ambulatory (outpatient) services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse treatments, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, and pediatric services including oral and vision care.

Rather than spell out in detail what specific treatments, products, and services should be covered in each of these categories, HHS is going to allow states to select a "benchmark plan" that will become the baseline for that state. States can choose their benchmark plan from among the three biggest private small group plans, the three biggest state employee plans, the three biggest federal employee plans, or the state's largest commercial HMO.

Several categories of required benefits, such as pediatric vision and oral care, might not be covered in some of these plans, so HHS has made special provision for those. (And in case you were wondering, HHS has no intention of requiring plans to pay for orthodontia that's not medically necessary—the only treatment specifically excluded.)

People who need mental health services may find their coverage greatly improved. Currently, the federal mental health parity law says that health plans have to cover mental health the same way they cover any other medical need—but only if they cover mental health care at all. And right now, 18 percent of people in individual plans have no mental health coverage. But mental health care is an "essential benefit," so after 2014 all plans will have to cover it, and on the same terms as any other doctor or hospital treatment.

Read more about health insurance and health reform.

Source:
Essential Health Benefits, HHS Informational Bulletin [HHS]

—Nancy Metcalf