Pre 2014 Major Medical vs Post 2014 Major Medical

One of the reasons I got back into this industry is due to the major change going on in the Health Insurance industry.  Understanding the changes has proven quite a task, and with my background as an educator, I feel that I can assist people in a way that few other agents can.  You can request a link to my LinkedIn account by contacting me.

Prior to January 1, 2014, Major Medical plans had to conform to state guidelines.  It was an insurance company's job to provide the state insurance commissioner with the details of their plan.  Once approved, they could sell their insurance plan within that state.

This meant that across the country, health plans could vary greatly, even under the same carrier.  Generally though, insurance carriers would have a specific product and make them available in certain areas where they were competitive.   In each state across the county, the laws differ and one would find that the plans available are much different also.  Pennsylvania has a very different selection of health plans than Florida.

After January 1, 2014, Major Medical plans (that are considered ACA-compliant OR QHP - Qualified Health Plans) have to conform to BOTH state and federal guidelines.  The guidelines define 10 essential benefits that are required of ACA-compliant plans.  Some of these benefits may be subject to deductible/coinsurance amounts.

These essential health benefits include at least the following items and services:

1. Outpatient care—the kind you get without being admitted to a hospital
2. Trips to the emergency room
3. Treatment in the hospital for inpatient care
4. Care before and after your baby is born
5. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
6. Your prescription drugs
7. Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
8. Your lab tests
9. Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
10. Pediatric services: This includes dental care and vision care for kids

Out of pocket maximums are also capped.  This includes deductibles (the amount you pay prior to the insurance company paying, except for copays in most cases) and coinsurance (the costs you share with the insurance company).  It also puts insurers on a much more even paying field as across the country plans are more similar and inclusive of benefits.

As we move forward, access to network providers will be the main difference in plans.  Again, if you are healthy you may not need to have access to the Mayo Clinic as an example.  If you do have some medical issues, you may need access to specific types of facilities.  The expansiveness of these networks also may be a factor in the premium calculation.

For assistance in navigating the complexity of the new health options, please contact me through psyberquote.com .