Q: After a huge federal health initiative was passed, why can’t my kids get insurance coverage for autism?
A: The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (Affordable Care Act) sets the table for dramatic change. Depending on how the legislation is implemented, health plans with mandatory coverage for children with autism spectrum disorders (ASDs) could be made available for all families. The changes include (1) defining “essential health benefits” for health plan coverage, and (2) Affordable Insurance Exchanges. Unfortunately, these changes will not be effective until 2014.
Q: What are “essential health benefits.”
A: Kathleen Sebelius of the Department of Health and Human Services, announced that, starting in 2014:
“The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures plans offered in the new Health Insurance Exchanges, and in the individual and small group markets, offer a package of essential health benefits that are equal in scope to what employers typically offer today.”
The Affordable Care Act defines these essential health benefits to include:
“at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.”
The Department of Health and Human Services is responsible for developing the essential health benefits package. In the fall of 2011, HHS will launch an effort to collect public comment and hear directly from all Americans who are interested in sharing their thoughts on this important issue. Learn more about this process.
Q: What are “Affordable Insurance Exchanges?”
A: Affordable Insurance Exchanges are designed to make buying health coverage easier and more affordable. Starting in 2014, Exchanges will allow individuals and small businesses to compare health plans, get answers to questions, find out if they are eligible for tax credits for private insuranceor health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs. See more here and here and here.
Q: What changes will take place in 2014?
A: The Affordable Care Act provides that, starting in 2014, processes must be implemented to improve the quality of health care and lower costs (see timeline):
“Making Care More Affordable. Tax credits to make it easier for the middle class to afford insurance will become available for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. (In 2010, 400% of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower your premium payments each month, rather than making you wait for tax time. It’s also refundable, so even moderate-income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles). Effective January 1, 2014. Learn how the law will make care more affordable in 2014.
“Establishing Affordable Insurance Exchanges. Starting in 2014 if your employer doesn’t offer insurance, you will be able to buy it directly in an Affordable Insurance Exchange. An Exchange is a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges, and you will be able buy your insurance through Exchanges too. Effective January 1, 2014. Learn more about Exchanges.
“Increasing the Small Business Tax Credit. The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50% of the employer’s contribution to provide health insurance for employees. There is also up to a 35% credit for small non-profit organizations. Effective January 1, 2014. Learn more about the small business tax credit.”
These general answers may or may not apply to your specific circumstances. You should consult a lawyer or other specialist if you think you are entitled to benefits that you do not receive or if you think your rights have been violated. Behavioral Lifeboat can help you do that.