One Plan Doesn't Fit All: The Impact of Health Care Reform on Specialty Coverage

One Plan Doesn’t Fit All: The Impact of Health Care Reform on Specialty Coverage

There has been plenty of conversation on how health care reform will make it easier and more affordable for consumers to receive preventive care and general wellness checks. But when it comes to health care, we all have unique and specific needs – one plan will certainly not fit all – and it raises important questions about those with special conditions, such as diabetes or sickle cell anemia (SCA). Will health care reform impact coverage for such conditions, and if so, how?

Under the health care reform law, most health insurance providers are required to cover a minimum package of health benefits, referred to as Essential Health Benefits, which encompass 10 categories of coverage.

Many aspects of specialty care and treatment are covered under the Essential Health Benefits, including:

  • Ambulatory patient services: Covers outpatient treatments and procedures that don’t require hospital admittance. This includes procedures to help treat special conditions, such as a check-up in a doctor’s office.
  • Chronic disease management: Covers doctor visits and ongoing treatment for chronic specialty conditions such as asthma, diabetes and osteoarthritis.
  • Mental health and substance use disorder services: Ensures individual and small group health insurance policies offer mental health and substance abuse benefits for the treatment of conditions like anxiety, depression, Obsessive Compulsive Disorder (OCD) or drug addiction.
  • Rehabilitative and habilitative services and devices: Covers services such as physical or occupational therapy, and medical equipment including orthopedic braces.

While health care reform will require many plans to provide some form of coverage for the categories mapped out in the EHBs, the depth and level of coverage will vary; consumers with special conditions will want to explore their options. One new resource for this information is the Health Insurance Marketplace, where consumers can compare plans and get information to help them decide which will best fit their specific needs.

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Photo Credit: George Redgrave

Updated: 11/19/14

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