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Essential Health Benefits

WHY THEY MATTER TO SOMEONE WITH HIV…

Obamacare, also known as the Affordable Care Act, or ACA, establishes a minimum set of benefits that must be covered by certain plans. These benefits are called Essential Health Benefits, and they include many health services that are important to quality HIV care. The Essential Health Benefits are required for all plans available through the new health insurance marketplaces, and for Medicaid state plans, beginning in 2014. The new requirements may also boost benefits, for example for preventive services, for people with existing health coverage through their jobs or from another source.

These Essential Health Benefits fall into the following ten categories:

Prescription drugs:

Medications prescribed by your doctor, including antiretrovirals for the treatment of HIV. Plans will vary in the specific drugs they cover.*

Hospitalization services:

Overnight hospital stays, often called inpatient care. These benefits are especially important because the Ryan White HIV/AIDS program is prohibited from paying for hospital care.

Ambulatory patient services:

Services typically provided in a doctor’s office, or at a hospital on an outpatient basis. Often called doctor benefits, they are used to prevent, diagnose or treat health conditions. For financial and other reasons, many people with HIV do not have a regular doctor to monitor and treat them. A regular doctor is essential for quality medical care and is covered under this benefit.

Emergency services:

Services provided in a hospital emergency room (ER) to treat an urgent or life threatening condition.

Mental health and substance use disorder services: 

Services from psychiatrists, psychologists and other mental health providers, and for treatment of alcohol and drug dependency and abuse. Mental services can also include counseling for specific HIV-related problems, such as dealing emotionally with a diagnosis or working through issues commnicating in a relationship.

Laboratory services: 

Tests and diagnostic services such as x-rays, CD4 counts, and viral load tests ordered by your doctor.

Preventive and wellness services and chronic disease management:

Services such as vaccines–including flu shots, hepatitis vaccinations and more–and other prevention services like HIV screenings, cancer screenings and preventive services for women. All private health plans other than those that existed prior to March 23, 2010 and have “grandfathered” status  must provide coverage for these preventive services and may not charge anything. This includes any new employer-based insurance, and any employer-based insurance that has changed significantly since 2010.

Maternity and newborn care:

Services provided during pregnancy and after childbirth, including services for delivery of newborns. Maternal and newborn care is especially important for women living with HIV, because with proper treatment, HIV-positive women are far more likely to give birth to healthy, HIV-negative babies.

Rehabilitative and habilitative services and devices: 

Services to help people regain or maintain their ability to function and perform activities of everyday life.  For example, physical or occupational therapy for recovery from an injury or to help those with disabilities maintain their ability to perform a key function, such as walking.

Pediatric services:

Medical services provided to children, including dental and eye care, services to support healthy development and services to treat any disease or condition.

 

*While all plans must cover all of these categories of benefits, they are not required to cover all services within a category. Health plans are permitted to establish their own rules for determining when a service is eligible for coverage.  Federal rules set higher standards for some benefits.  For example, every health plan must cover at least one drug in each drug class, but they are not required to cover all drugs within a class.  People with HIV depend on broad access to prescription drugs. Health insurance plans may establish what’s known as a ‘formulary’, a list of the specific drugs they will cover.

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What you need to know

We have made every effort to provide accurate information on this portal, but you should contact the marketplace or Medicaid agency in your state for guidance on your specific situation. Click here to find contacts in your state. All data on the site were updated April 2014 and are subject to change.

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