The 10 ‘essential benefits’
The Affordable Care Act requires that new policies provide at least 10 “essential health benefits,” including:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance abuse treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
The Affordable Care Act mandated that insurance policies for individuals provide 10 “essential health benefits,” including emergency services, mental health treatment, maternity care, lab work and prescription drugs.
An existing plan that didn’t comply would be canceled, and the policy holder would be forced to acquire a plan with all of the essential health benefits. The provision enraged millions of consumers, who said the new standard was forcing them to pay for additional benefits they didn’t need or want.
So the Obama administration delayed the effective date of the requirement for two years, meaning people and businesses with “noncompliant” plans could keep them — if their insurer allows it — until October 2016.
The 2015 “open enrollment” begins Nov. 15, and policy holders will soon receive renewal or noncompliant letters from their insurance companies.
Last year about 400,000 Georgians had individual plans that didn’t meet the new standards, and many of them took advantage of the reprieve. Now they’re back to making the same choice as last year: keep the old plan for another year, if the insurance company lets them, or shop on the Health Insurance Marketplace for a new policy.
Elise Miller, 64, of Americus intends to stick with her old plan. The retiree sees the renewal of Blue Cross and Blue Shield policy as a bridge to July when she turns 65 and becomes eligible for Medicare.
Miller says her health care costs have increased every year since 2005 when she retired from Heery International in Atlanta.
“We’re living on Social Security supplemented with some rental income,” she said.
Her monthly health insurance bill is $487 with a $7,500 annual deductible. Miller says she had the option of paying about $200 with a subsidy under an Affordable Care Act plan, but her aversion to Obamacare is such that she decided to forgo the savings.
“I didn’t agree with that philosophy,” she said. “I don’t have a lot of respect for the Affordable Care Act.”
Connie Wise, who also lives in Americus, says she’d welcome a plan that is both compliant and affordable. When the health care law passed, Wise learned she did not qualify for Obamacare because of her part-time employment status at a state agency.
“I’m working to pay health insurance,” Wise said.
The $10,000 deductible that she and her husband pay covered this year’s medical costs following his diagnosis for congestive heart failure, she said. “Now anything he needs to have checked, he’s having it done before the year ends.”
Wise said she worked an unlimited number of hours before the health care law passed. But her employer has since her reduced hours to remain within the health insurance guidelines for full-time vs. part-time staff.
Employers with 50 or more employees that do not provide adequate insurance under ACA face a penalty. Health care experts agree that some business owners may elect to take the penalty.
“Many are concerned because of the cost or affordability and may elect to pay the fine instead of offering benefits to employees,” said Joe Aitchison, vice president at BASIC, which assists employers with benefit administration and human resources. “They would end up paying less (for fines) than offering benefits.”
Although the law does not require it, Max McAllister has provided health insurance for employees at Traxxion Dynamics for nearly 17 years. The business, which makes motorcycle suspension components in Woodstock, has 10 workers. McAllister fully paid their premiums until this year, when his insurer jacked up the price 75 percent. He found a new insurer but is still paying more.
“When your renewal comes up is when you get ready for the shock and awe,” he said. “For the first time my employees have to pay a small portion to cover the increase.”
McAllister’s employees pay $3,000 in annual deductibles, an increase from $1,000. As a result, health care has become more of a burden than help, the business owner said.
“If you’re an employee making $20,000 a year, $3,000 can break a person,” he said. It’s a lot if you’re making $50,000. It’s unbearable is what it comes down to. I refuse to call it ‘affordable health care’; I call it Obamacare.”
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