Why your health insurance premium could increase under the Affordable Care Act

Why your health insurance premium could increase under the Affordable Care Act

TIGARD, Ore. – Is the Affordable Health Care Act making health care unaffordable for some people?

Some customers of Regence Blue Cross Blue Shield, one of Oregon’s largest insurance providers, say that's exactly what's happening. They say they are finding their health care plans are dramatically changing under the Affordable Care Act.

“Policy holders are seeing almost double their monthly premiums,” said a KATU viewer named Larry in an email. He said his wife’s premium will increase by $300 under the Affordable Care Act.

Cover Oregon spokesman Michael Cox says most insurance plans that focus on lower premiums and higher deductibles will be replaced by plans with lower deductibles and higher benefits.

“January 1, 2014 is really a new era of health care and a lot of things are changing,” said Cox.

The Affordable Care Act mandates that the plans include ten essential benefits, from care for pregnant mothers to substance abuse treatment.

The issue, according to Regence spokesman Jared Ishkanian, is you’ll have to pay for those benefits even if you don’t use them all.

“The Affordable Care Act increases access to coverage and enhanced benefits, but these come with additional costs. For those members on individual plans that will no longer be ACA-compliant starting on January 1, it’s important to remember that these members are seeing new rates for new health plans with new benefits,” said Ishkanian in an email to KATU.

“Whatever plan you have is going to be better in a lot of ways than the plans that had to end at the end of the year because they didn’t offer enough benefits,” said Cox.

People who pay for their own insurance don’t have to re-enroll with the same insurance company.

Essential Health Benefits

The Affordable Care Act requires that non-grandfathered health plans offered in the individual and small group markets, both inside and outside of the new Health Insurance Marketplace (or “Exchange”), cover a core package of health care services known as Essential Health Benefits. These plans must cover – at a minimum – the following 10 general categories:

Ambulatory patient services – Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center. Also included in this category are home health services and hospice care (note: some plans may limit coverage to no more than 45 days).

Emergency services – Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. Typically, this is a trip to the emergency room, and includes transport by ambulance. You cannot be penalized for going out-of-network or for not having prior authorization.

Hospitalization – Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board. Hospitalization coverage also includes surgeries, transplants and care received in a skilled nursing facility, such as a nursing home that specializes in the care of the elderly (note: some plans may limit skilled nursing facility coverage to no more than 45 days).

Laboratory services – Testing provided to help a doctor diagnose an injury, illness or condition, or to monitor the effectiveness of a particular treatment. Some preventive screenings, such as breast cancer screenings and prostrate exams, are provided free of charge.
Maternity and newborn care – Care that women receive during pregnancy (prenatal care), throughout labor, delivery and post-delivery, and care for newborn babies.
Mental health services and addiction treatment – Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder (note: some plans may limit coverage to 20 days each year).

Rehabilitative Services and devices – Rehabilitative and habilitative services and devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition. Plans have to provide 30 visits each year for either physical or occupational therapy, or visits to the chiropractor. Plans must also cover 30 visits for speech therapy as well as 30 visits for cardiac or pulmonary rehab.

Pediatric Services – Care provided to infants and children, including well-child visits and recommended vaccines and immunizations. Dental and vision care must be offered to children younger than 19. This includes two routine dental exams, an eye exam and corrective lenses each year.

Prescription drugs – Medications that are prescribed by a doctor to treat an illness or condition. Examples include prescription antibiotics to treat an infection or medication used to treat an ongoing condition, such as high cholesterol. At least one prescription drug must be covered for each category and classification of federally approved drugs.

Preventive and wellness services and chronic disease treatment – Preventive care, such as physicals, immunizations and cancer screenings designed to prevent or detect certain medical conditions. Also, care for chronic conditions, such as asthma and diabetes.

Information from Regence Blue Cross Blue Shield.