The news over Medicaid expansion continues in the capitol but one point is clear: North Carolina is allowing the federal government to set up a Health Insurance Exchange, which will become available to the general public on Oct. 1. Today, we will discuss some of the 10 essential benefits that will be offered within the Bronze, Silver, Gold, or Platinum Plans — 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.
A new benefit which was much needed is coverage for pediatric services for oral and vision. Starting Jan 1, 2014, all pediatric well‐child visits, which will include physical exams, immunizations, hearing and vision screenings, developmental and behavioral screenings, and anticipatory guidance, will not have a deductible or co-payments. This will address the concern many parents have about not being able to afford the multiple payments for more than one child. Some of the benefits being added are testing for autism, depression,obesity and hemoglobin.
Preventative and wellness services for adults will now cover cholesterol screening, depression testing, colorectal cancer screening and type 2 diabetes screening for men. For women, some new additions have been included, including breast cancer mammography screenings, cervical cancer screening, and contraception services. These benefits are only a few of the more notable services being added. In addition, these preventive services will not be subject to co-payments or co-insurance or having to meet a deductible. However, the services must be delivered by a network provider.
Initially the Affordable Care Act only required insurers to offer just one drug per drug class to individuals and small-group plans. For example, there would only be one cholesterol drug, one anxiety drug. In other word, one drug for each drug class. The Obama administration re-thought the process and has recently made changes to this coverage. According to the Kaiser Group, a health care foundation, the federal government is going to match what some states are offering in their proposed State Insurance Exchange. The bench mark goal is about 62 percent of drugs available in different drug classes. As usual, there is a wide difference in what some states are going to offer to the public for their bench mark. In states like California, they meet only 26 percent of the available drug classes and states like Mississippi are offering a high of 93 percent of the drug classes.
What is going to happen in North Carolina? At this moment, it’s an unanswered question. On one level, people who have no prescription service will be happy to now have coverage for some of the more common drugs available on the market place. On the other hand, there will be some drugs, especially drugs that treat certain cancers, that most likely will not be covered under the federal health plans that will be offered to North Carolina residents. As we get closer to the summer, the Obama administration will put more specific recommendations together about prescription coverage.
Mental health benefits will see expanded coverage under the ACA program. Many existing health plans for individuals and small business have very limited mental care benefits or none at all. Under the new coverage, everyone will get basic services such as screenings and office visits. An area of concern brought up by many observers is the coverage will be there, but the doctors are not. It is no secret that even with existing health plans, it is typical to have extensive wait times, some as long as a month before seeing a doctor.
Since I have begun this series there have been changes made to the Affordable Care Act. I believe this ever changing environment will continue. Since the full program does not go into effect until Jan. 1, 2014, I fully expect more revisions to occur.
Darek Hunt, a Lumberton resident, has his master’s degree in Public Policy and Administration and is a doctoral student in Health Sciences. He specializes in health care administration and health policy.