March 7, 2013:
Health plan coverage of maternity, pediatric, mental health care falls short of new federal standards, which go into effect in 2014
A new analysis by HealthPocket, Inc., finds that less than 2 percent of health plans available to consumers today satisfy all aspects of the “Essential Health Benefits”—that is, the set of healthcare service categories they must offer starting in 2014, as mandated by the Affordable Care Act. The analysis shows that on average, plans cover just three-fourths of benefits now deemed essential, leaving a significant gap between what’s covered currently, and what will need to be covered starting next January.
In February, the U.S. Department of Health and Human Services released their final rule for Essential Health Benefits. A number of Essential Health Benefit categories, including ambulatory care, emergency care and hospitalization services, are currently covered by all or nearly all existing health plans. However, gaping holes were found in maternity and newborn care, which was covered by only 34 percent of plans, pediatric dental and vision care (24 percent) mental health services (61 percent) and substance use disorder services (54 percent).
“It’s important for consumers to understand that these coverage gaps currently exist in the plans available today. Just like preexisting condition exclusions allow health plans to avoid paying for certain risks, the coverage gaps we see in this report are another way that plans can currently elect to not cover certain healthcare costs,” said Kev Coleman, head of research and data at HealthPocket. “Coverage will become more complete starting in 2014, and the vast majority of plans in the market today will no longer be sold after the end of this year in their present form.”
Coverage varied by state, with Alaska health plans averaging the lowest percentage of covered Essential Health Benefits at 66 percent, followed by plans in Wisconsin (67 percent), Texas (68 percent), New Hampshire (68 percent) and Louisiana (69 percent). Massachusetts plans had the highest percent of covered essential benefits at 94 percent, followed by Rhode Island (93 percent), Hawaii (90 percent), California (89 percent) and Maryland (89 percent).
The results of the study were based on an analysis of 11,100 health insurance plans for individuals and families under the age of 65. This HealthPocket InfoStat is fourth in a series using health plan data to produce objective, meaningful, and clarifying information and guidance for consumers.