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Health Care Reform: What's Covered

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Updated: 11/02/2011 10:24 am

With all the talk about the Affordable Care Act, the details about what health plans will be required to cover can get lost in the shuffle. 

WebMD readers want details about exactly which benefits and medical services they’ll have access to under the new law. 

Here are answers to some of the most common questions.

Q: How will the exchanges work?

A: Health insurance exchanges will be marketplaces where small businesses and individuals who don’t get health insurance through their employer can shop, compare, and purchase health plans. 

The exchanges, which will be up and running in 2014, will offer health care consumers the full range of private and public health insurance options available to them in their state.

The goal of the exchanges is to make it easier for small businesses and individuals to compare health plans side by side and to evaluate price, quality, and provider networks prior to signing up.

By pooling millions of people together in this marketplace, small business and individuals will gain the same bulk purchasing power large employers have, creating more competition among insurance companies, with the goal of driving down costs. 

Tax credits will be made available to people buying insurance on the exchanges to make care more affordable.

Q: Who will run the exchanges?

A: Each state has the option of creating and operating its own health insurance exchange(s), and will be offered federal money to do so. 

Each state may also choose to opt out of running its own health insurance exchange(s), in which case the federal government will do so on its behalf.  

Q: Where can I get a copy of the law? Is it online?

A: Yes, the Affordable Care Act is online and available for anyone to read.

The law, in full, is available by section on Healthcare.gov under the heading About the Law. The government’s web site also breaks down each provision. And you can learn about when various aspects of the law take effect on the timeline of what’s changing and when.

Q: Is mental health covered? And if so, is there a limit on how many therapy sessions a patient in need can have in a year?

A: Yes, mental health services will be covered.

Health plans sold in health insurance exchanges starting in 2014 will be required to offer consumers an “essential benefit package.” This package must include mental health and substance abuse benefits.

Though no specific number of therapy sessions will be established, the law does require that plans comply with Mental Health Parity law, which states that mental health and medical benefits must be treated equally. That means that out-of-pocket costs and benefit limits must be the same for mental health care as for medical care. Also remember that as of last year, the Affordable Care Act did away with lifetime limits to coverage and restricted annual limits, two provisions that apply to both medical and mental health care.

Still, there are details that have yet to be worked out. For example, the way in which covered benefits and medical necessity are ultimately determined by insurers is not clear and is under consideration by the Institute of Medicine (IOM), which will make recommendations to the government.

If you get your insurance through your employer, parity laws are already in effect if your employer has 50 or more workers and offers mental health benefits.

For more information on mental health coverage, see my WebMD Health Insurance Navigator blog on this topic.

Q: Will dental, vision, alternative care, physical therapy, and in-vitro fertilization (IVF) be covered?

A: The law establishes general categories of services that must be included in a health plan’s essential benefit package, yet the scope of those services is a work in progress.

According to Kelly Traw, a principal in the Washington, D.C. benefits consulting firm Mercer, the law directs the U.S. Department of Health and Human Services to further define which services would ultimately be included under each service category. The law also states that the scope of benefits must reflect those provided by a typical employer-sponsored health plan. “The Department of Labor is conducting a survey to inform that determination,” Traw says. “There aren’t black-and-white rules right now.”

Here’s what we do currently know:

  • Dental care -- All qualified health plans sold on the health insurance exchanges must include dental care coverage for children and adolescents younger than 21, though the scope of those benefits have yet to be determined.  There are no requirements for dental coverage for adults.
  • Alternative medicines -- The law prohibits discrimination against any groups of providers, including chiropractors, but it’s unclear exactly which benefits for alternative care will be included.
  • Vision care -Vision care for children will be included in the essential benefits packages.
  • Physical therapy -- The law states that rehabilitative services and devices must be included. It's reasonable to assume that physical therapy might fall into this category. How and what the scope of those services will be, however, is still being worked out.
  • In vitro fertilization (IVF) -- The law does not indicate that IVF will be a covered service.

Q: Are part-time workers included?

A: Beginning in 2014, anyone who does not get health insurance through his or her employer would be eligible to purchase health insurance on the health insurance exchanges.

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