September 30, 2013
For all the uncertainty about whether consumers and taxpayers can afford Ohio’s new federally run health-insurance marketplace, there’s no question that the coverage available through it will be more comprehensive than in the past.
That’s by design. In most cases, consumers can no longer buy policies that offer bare-bones coverage for only the costliest of medical emergencies. Instead, their coverage must include a bundle of “essential health benefits” as mandated by the Affordable Care Act.
And no annual or lifetime dollar limits can be placed on those benefits or services.
One of the most-significant changes: a requirement that plans include maternity care in their coverage. The U.S. Department of Health and Human Services said two years ago that 62 percent of enrollees who buy their own health insurance did not have coverage for maternity services. About 8.7 million Americans will gain such coverage through the individual and small-group markets next year.
“When you were buying coverage in the individual market in the past, that was typically not a covered benefit,” said Amy Rohling McGee, president of the Health Policy Institute of Ohio. “You needed to get a rider, which cost significantly more, to cover maternity care.”
Prescription drugs will be another area of interest for policyholders. Some insurers might offer somewhat-limited formularies, but consumers should see coverage improve, said Gary Claxton, a vice president with the Kaiser Family Foundation.
In the past, he said, “there were a lot of plans that didn’t cover prescription drugs in a meaningful way.”
Advocates who want better coverage of mental-health and addiction services still have questions about the level of coverage that insurers will offer in Ohio. Determining the benefit levels in public documents that health-insurance companies have submitted to the Ohio Department of Insurance has been difficult, said Donna Conley, CEO of Ohio Citizen Advocates.
“It has been a huge barrier to really look at what those plans are offering,” Conley said. “It is not clearly laid out.”
In some cases, coverage levels for physical rehabilitation and habilitation services for those diagnosed with autism are unclear, said Kathleen Gmeiner, director of Ohio Consumers for Health Coverage.
Advocates also have concerns about whether the Ohio insurance plan that will set the minimum bar for benefits coverage - a plan offered by Anthem Blue Cross and Blue Shield - provides sufficient coverage for mental-health services.
“We are currently and will continue to be fully compliant with the Mental Health Parity laws,” Anthem spokeswoman Kim Ashley said in a prepared statement. “All of the choices we have made about doctors and drugs covered, pricing and co-pays were done to deliver affordability and quality on a sustainable basis, within the requirements of the Affordable Care Act.”