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Changes under the law, at a glance

What's in an Obamacare health insurance policy? You're still buying insurance from private companies, but what the policies must cover at minimum is mandated by the Affordable Care Act.

Also, you will be able to compare policies and companies much more easily than in the past.

Though all plans must cover the 10 essential health benefits, there are four categories of cost, ranging from lowest-premium "bronze'' plans to highest-premium "platinum" plans.

The essentials

Requiring that certain services be covered will make health plans more costly than bare-bones policies. But they'll also be more comprehensive.

Starting next year, the rules will apply to all plans offered to individuals or 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 covered benefits are:

• ambulatory patient services

• emergency services

• hospitalization

• maternity and newborn care

• mental health and substance abuse services, including behavioral health treatment

• prescription drugs

• rehabilitative services and devices

• laboratory services

• management of chronic diseases, and preventive and wellness services

• pediatric services, including dental and vision care (which are not included for adults)

Pre-existing conditions

This is a major change under the law. Starting in 2014, most plans — whether obtained through an employer or on the marketplace — cannot deny coverage or charge more money because of a pre-existing health condition. Nor can plans charge more to women than men. But in most states, including Florida, they may charge more based on age and smoking status.

If you have a grandfathered individual plan — a plan you buy yourself that was in existence before March 23, 2010, and has not changed — then the pre-existing condition rule would not apply. So check the details of your plan and consider shopping around.

Pick your metal

People will be able to choose from insurance plans with differing levels of coverage and varying costs for copays and premiums. The categories do not reflect the quality or amount of care the plans provide.

It's an important choice: Do you go for a "bronze'' plan with lower premiums, knowing that it covers only 60 percent of typical medical costs? Or do you pay higher premiums for a silver, gold or platinum plan that will cover a higher percentage of your costs?

Until you go to the marketplace and see what the various plans will cost — they can vary, even in the same category, among insurers and states — and what kind of subsidies you may qualify for, you can weigh your health care needs. In general, plans with higher coverage levels are a better bet for people who use more health services.

The marketplace also offers lower-cost "catastrophic" plans to people under 30 and to some people with very low incomes, but these do not include the 10 essential benefits, and you can't use a subsidy to offset their cost.

Out-of-pocket costs, lifetime 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.

Also, most insurance plans will be prohibited from setting lifetime cost 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.

Adult children

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. 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.

Even in Florida — with one of the largest uninsured rates in the nation — most people have coverage through an employer, Medicare or Medicaid. They don't need to do anything with the Obamacare marketplaces when they open Oct. 1. But if you have an individual policy or are uninsured (and are above the poverty level), you'll likely be a marketplace shopper.

Changes under the law, at a glance 09/28/13 [Last modified: Saturday, September 28, 2013 5:53pm]
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