Services Covered

No matter what kind of coverage you have, it’s important to know what’s covered and what’s not. Starting in 2014, certain essential health benefits will be covered under all policies. In the meantime, the new law offers new options for preventive coverage and insurance for those with pre-existing health conditions.

• What services are covered under my insurance policy?
• How can I find out what’s covered under my insurance plan?

What services are covered under my insurance policy?

It depends on what policy you buy.  Coverage under many individual policies today can be very limited.  This will change.

Starting in 2014, new individual plans and plans purchased in an Affordable Insurance Exchange will have to cover essential benefits like hospitalizations, doctor services, prescription drugs, rehabilitation and mental health services, pregnancy, and newborn care. Also, there will be limits on how much you have to pay out-of-pocket each year for covered services.

An Affordable Insurance Exchange is a new marketplace where individuals and small businesses can buy affordable health benefit plans. Exchanges will offer you a choice of plans that meet certain benefits and cost standards.

Coverage for Preventive Care

Under the Affordable Care Act, new health plans must cover certain preventive services without cost sharing.

Coverage for Pre-Existing Conditions

• Children’s pre-existing conditions: In many states, your individual insurance policy might permanently exclude coverage for pre-existing conditions, including disabilities. However, under the Affordable Care Act, new individual insurance policies (and job-based plans) are not allowed to exclude coverage for pre-existing conditions or disabilities in children under age 19.
• Pre-existing conditions for anyone: Starting in 2014, these same policies will not be allowed to exclude coverage for pre-existing conditions for anyone.  
• Temporary exclusions in job-based plans: If you have job-based health coverage, the plan is allowed to exclude coverage temporarily for pre-existing conditions, including disabilities, usually for no more than one year.  If you had other coverage before joining your current plan, it must be credited toward the pre-existing condition exclusion period. Note: In 2014, for job-based plans, waiting periods for coverage of pre-existing conditions will be limited to 90 days.

Coverage for Pregnancy under Job-Based Plans

Under your job-based plan, pregnancy cannot be considered a pre-existing condition. In addition, newborns and adopted children who are enrolled within 30 days of birth or adoption cannot be subject to a pre-existing condition exclusion.   Learn more about HIPAA’s preexisting condition exclusion period.

Coverage under Small Employer Policies

For small employer insurance policies, states vary on what they require insurers to cover. Contact your State Department of Insurance for more information about small employer coverage requirements in your state.

How can I find out what is covered in my insurance plan?

Read your policy.  Often this is hard to do.  Insurance policies can be complex documents and not always easy to follow.  Call your insurance company for more information about what your policy covers.

Starting in 2012, all insurance papers must be written in clear and understandable language that explains what’s covered and how it works, so you can understand your choices more clearly and decide what coverage is really best for you.

Health Plan Summaries

• Summary plan descriptions:  Job-based health plans are required to provide a summary plan description to all members. The summary plan description explains what the plan covers, what costs you are responsible for, how to appeal disputes, and other important information. Sometimes claims procedures are in a separate booklet that‘s handed out with your summary plan description.
• Questions on job-based insurance? Ask your benefits office or plan administrator at work for help with problems or questions about your job-based health plan. The Department of Labor website has more information on job-based plans.

More Information on What’s Covered

• If you have questions or concerns about what’s covered under your job-based plan, you can contact the U.S. Department of Labor.  Their benefits advisors can help you get answers to questions about your rights under federal law.
• If you have individual insurance, find consumer assistance in your state for more information about your coverage rights and protections.