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So, should all health plans have to cover all things, or should we have some choice in what we buy?

2017-07-07 by Colleen King

The goal with the Affordable (?) Care Act (ACA) was to cover the majority of health care related expenses for the most people possible. But did it go overboard?

Plans cannot have a 'life time maximum' anymore, but that's a big disingenuous because the majority or people never come near the $1-$7 million life time maximums a lot of plans had, ALL plans have to cover the 10 Essential Health Benefits outlined by the law, which include the following:

  • Outpatient care
  • Emergency Room Services
  • Inpatient Hospitalization
  • Maternity Care
  • Mental Health/substance abuse treatment
  • Prescription drugs
  • Habilitative/Rehabilitative service (things like physical therapy)
  • Lab services
  • Preventive services
  • Pediatric care, including the beloved Pediatric dental and vision

On the surface, this makes sense to an extent, but when you have to consider all of these items have to be 'priced in,' that drives up costs. Pediatric dental and vision is probably good, but I have a lot of clients not thrilled with this because either they don't have kids, or their kids are over 19 so they aren't covered. The same argument could be used for maternity care. It's covered across the board, whether you're male, over the common age to have a baby, whatever.

So here are my thoughts on what could be workable, based on what my clients have been happy with in the past, and would like to see now...

Maternity care--we used to have plans that did not cover maternity, which was okay for people not planning on having babies. Carriers should be able to offer plans that don't cover maternity, but to keep cost on maternity plans reasonable, there should be a requirement that it be covered on a certain percentage of plans, maybe 50% of what they offer?

Prescriptions--We used to have plans that covered generic drugs only, or some that had no prescription drug coverage. I don't necessarily want to go back to NO drug coverage, but people liked the 'generics only' plans, knowing that they might get hit if there was a brand drug needed. They were willing to take the chance.

Pediatric dental and vision--this may be a good thing, but there are NO dollar limits on the amount of pediatric dental care, and no waiting periods for major services. Braces are covered, but only when 'medically necessary,' and as most of us know, often times braces are more cosmetic in nature. Any time there are no 'limits,' you're setting things up to be taken advantage of. Maybe there needs to be an annual limit, more generous than the typical $1000/year, but not unlimited.

Habilitative/rehabilitative care--this is a tough one. There don't appear to be limits on the number of visits, it's going to be based on 'medical necessity.' These are services like physical therapy, occupational therapy and speech therapy. There are many scenarios that are not '12-20 visit' situations but when I was a utilization management nurse years ago, we saw a ton of abuse in PT and chiropractic care. And speaking of Chiropractic care, it's not a 'required' service, and now most plans don't cover it! Can we go back to this at least being covered in some way under the physical therapy benefit? That's nuts!

The rest of these are pretty broad, it would take weeks of writing to delve into these. We used to have higher deductible plans, some with  50% coverage after meeting the deductible. Plans like that weren't for everybody but for some of my older clients, they liked those because it helped to keep premium costs down, they had savings if something happened. I heard many times from clients 'I just don't want to lose my house if something major happens.' Makes sense! Let's bring back some sanity to all of this.

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Category: Health care reform