by Sydney Frazer, Stride Health
There’s no doubt about it—health insurance can be expensive, especially as a freelancer when you are responsible for covering all of your premium (if you don’t qualify for subsidies). One of the best things you can do to make the most of the money you’re paying is understand and take advantage of everything that comes with your plan. Under the Affordable Care Act, all plans sold on the marketplaces, both federal and state, are required to cover certain benefits and care. Two of the most important pieces of this are essential health benefits (EHBs) and free care. Keep reading so you are familiar with these pieces of ACA plans and can take advantage of them.
Recognizing the 10 Essential Health Benefits
Regardless of your plan, plan network, and carrier, your ACA plan will cover ten essential health benefits. The goal behind this is that everyone has access to coverage that is comprehensive and encompasses services peoples actually need. The percentage that these benefits are covered depends on the metal tier of your plan. These ten essential benefits are as follows:
Laboratory services - This covers services like x-rays, MRIs, blood and fluid tests, biopsies, and pregnancy tests. Tests that are considered preventive in nature, like STD testing and mammograms, are free to you.
Emergency services - Say you are having heart attack symptoms and go to the emergency room. Not only is a percentage of your visit covered, you also don’t need to have preauthorization for that actual visit. Additionally, you won’t be charged extra for going to an emergency room that is out-of-network.
Prescription drugs - Your plan must cover at least one drug per category and class. A category and class refers to a group of medications that are used to treat the same health condition. Individual states set their list of covered medicines, so some states cover more than one medication per category and class.
Mental health and substance use disorder services - This includes treatment for alcohol, drugs, and other substance abuse, as well as therapy and inpatient mental health services. However, coverage might be limited to a certain number of visits per year and come with a steep copay.
Maternity and newborn care - This includes things like prenatal care, childbirth, and your infant’s initial care.
Pediatric services, including oral and vision care - Unlike health insurance for adults, health insurance for children under the age of 19 must cover both dental and vision care. This includes two cleanings per year, x-rays, and fillings, as well as an eye exam and one pair of glasses or contact lenses per year.
Rehabilitative and habilitative services and devices - This includes things like therapy to help with pain, medical equipment (cane, wheelchair, etc), and therapy to rehabilitate functional abilities like speaking and walking.
Ambulatory patient services - These are outpatient services and care—aka when you go to an appointment at your doctor’s office, receive care, and leave.
Preventive and wellness services and chronic disease management - Preventive care is free. This is covered in-depth below, so keep reading!
Hospitalization - Your insurance plan must cover your hospitalization, which is a relief considering a day in the hospital can cost you anywhere between $2,000 and $20,000.
The degree to which these 10 essential health benefits are covered is dependent on the metal tier of your plan. Even if you have the lowest level metal tier, your plan will still cover a portion of these 10 EHBs. The average percentage of the medical expense that your plan covers is known as the actuarial value. The percentage you cover is made up in the form of your deductible, copayments, and coinsurance. Coverage by metal tier is as follows:
Bronze - With a bronze plan, the insurance company will pay for an average of 60 percent of the medical expenses and you will be expected to cover the remaining 40 percent.
Silver - With a silver plan, the insurance company will pay for an average of 70 percent of the medical expenses and you will be expected to cover the remaining 30 percent.
Gold - With a gold plan, the insurance company will pay for an average of 80 percent of the medical expenses and you will be expected to cover the remaining 20 percent.
Platinum - With a platinum plan, the insurance company will pay for an average of 90 percent of the medical expenses and you will be expected to cover the remaining 10 percent.
Using Free Care to the Max
Once again, all ACA plans, regardless of network type and carrier, will cover preventative and wellness services for free. The ACA mandates that your plan covers 100 percent of every preventive service recommended by the U.S. Preventive Services Task Force. This means you don’t even pay a copay or coinsurance (as long as you stay in-network)! There are 50 preventive services covered including things like immunizations, high blood pressure screenings, and mammograms. Some of the ones you should be familiar with include:
Immunizations - This includes vaccines for the flu, hepatitis A and B, HPV, measles, mumps, rubella, varicella, shingles, and tetanus.
Birth control - All women have access to FDA-approved contraceptive methods. Your carrier must cover 18 different contraceptive methods for women. Put simply: you have access to a wide variety of contraceptives and can choose the one that makes the most sense for you.
STD screening - You can get tested for diseases like chlamydia, gonorrhea, syphilis, and HIV.
Breast cancer screening - This applies to women over 40. You can get a mammogram at least every two years and as often as once per year.
Cervical cancer screening - This applies to women under the age of 65. This includes a Pap smear every 3 years.
Type 2 Diabetes screening - If you are over 40 and are considered overweight or obese, you qualify for a screening for abnormal blood glucose levels.
Depression screening - This is relevant for all adults. This screening should encompass diagnosis, treatment, and follow-up.
Hypertension screening - AKA high blood pressure screening. If you are an adult, you can get screened for high blood pressure.
Diet counseling - If you are at risk for cardiovascular disease, you can get counseling around how to adopt a healthy diet.
Keep in mind: your eligibility for some services is dependent on different factors including things like age, gender, and risk factors.
Even with subsidies, health insurance as a freelancer can be pricey. By fully understanding everything that comes with your ACA plan, you are in a much better place to use your plan to the maximum. Be sure to stay proactive by taking advantage of these services because you might just prevent a costly health care bill down the road!