It was one of the lighter moments in a House hearing Wednesday in which Health and Human Services Secretary Kathleen Sebelius testified about the government’s problem-ridden health insurance exchange. Rep. Renee L. Ellmers (R-N.C.) said the health-care law was forcing many Americans to pay for benefits they would never need, such as maternity coverage.
“To the best of your knowledge, has a man ever delivered a baby?” Ellmers asked. The back-and-forth focused attention on a key part of the law: Starting next year, individual plans must provide a minimum package of essential benefits — including maternity care — to everyone. What gives?
1. Let’s back up and put this in context.
Starting Jan. 1, individual policies must provide benefits similar to those in typical employer plans. These “essential health benefits,” as they are called, include prescription drugs, mental health treatment and inpatient hospital care. Some people have gotten notices from their insurance companies telling them their current plans are being canceled as of Dec. 31. In most cases, that’s because these plans don’t meet these requirements.
If insurers discontinue a policy, they are required to give consumers 90 days’ notice and offer the option of enrolling in an alternative policy.
2. Who is getting these cancellation notices?
Most Americans get their insurance through their employers. Or through Medicare, Medicaid or the Veterans Benefit Administration. These people aren’t affected.
But about 5 percent of Americans, up to 15 million people, buy their insurance on the individual market. Consumers in this market are the ones getting the notices. No one knows exactly how many notices are going out, but the figure is probably hundreds of thousands.
3. I’m a 58-year-old man. Why on Earth do I have to buy a plan that covers maternity care?
Many plans in the individual market have lacked what some considered key benefits, and the health law was designed to improve that situation. Right now, for example, insurance companies often charge women more for policies, even if the policies don’t include maternity benefits. The people who wrote the law didn’t want insurers to be able to discriminate against women, and they wanted to make the coverage suitable for different types of people, even if not everyone was going to use the all its services. Policy experts wanted to spread the risk across as large a group as possible.
4. Is there any benefits just for men?
Yes. Policies must cover preventive services, including one designed to check older men who have smoked for abdominal aortic aneurysms. Aneurysms can break open and cause dangerous bleeding and death.
5. Why was maternity care included?
Up until now, many policies on the private market did not cover maternity care as a standard benefit. Women who unexpectedly became pregnant would find, to their surprise, they weren’t covered for those services. In some cases, when they tried to switch, their insurance company would treat their pregnancy as a preexisting condition and not cover the cost.
6. What else is considered an essential benefit?
Doctor visits, hospitalization, emergency care, pediatric care, prescriptions, medical tests, mental health care, substance abuse treatment and more. Plans must also cover preventive care at no extra cost to consumers, including flu shots, routine vaccinations and cancer screenings, such as mammograms and colonoscopies.
7. Currently, I pay $300 a month for my individual coverage. My deductible is $2,700 a year. That plan is being canceled. The closest comparable plan will cost me more. Why?
Insurers base their premiums on several factors, including inflation and the cost of putting insurance rules in place. Under the health law, insurers will no longer be able to pick and choose who they want to insure. They must accept everyone, even those who are very sick. Under the old rules, insurers could decide whether they wanted to give you coverage — and how to charge — based on your answers to pages and pages of medical questions.
8. What should I do if I get a cancellation notice?
Consumer experts say people should carefully research their choices. Some insurers are giving people the option to renew current policies early, before Jan. 1. Those plans don’t have to include essential benefits. And they could mean more out-of-pocket costs.