In Health Law, a Clearer View of Coverage (NYT)

One of the most publicized aspects of the new health care act is a ban — starting in 2014 — on refusing coverage to people like Mr. DeLorenzo because of a pre-existing condition like AIDS.

Some 57 million Americans — 1 in 5 people under 65 — have diagnoses that could lock them out of coverage, according to a report issued this month by the advocacy group Families USA.

But the ban is not the only change likely to benefit middle-income Americans. Also starting in 2014, insurers will have to offer a clearly defined package of essential health benefits comparable to the coverage ordinarily provided by employer plans, including doctor visits, hospital care, emergency services, maternity and newborn care, lab work, rehabilitative services, chronic disease management, mental health and substance abuse services, and prescription drugs — along with the full cost of preventive services.

For plans sold on the competitive insurance exchanges established by the law, companies will have to provide information in a standardized format that makes it possible to compare different plans.

“Right now when you buy a policy, you might not know what the contents of that policy are, and what you’re responsible for out of your own pocket,” said Sara Collins, a vice president at the Commonwealth Fund, a private foundation that focuses on health policy. “Unless you spend a lot of time thinking about health insurance, you might not know the right questions to ask.”

Jennifer Tolbert, principal policy analyst at the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, said that under the new rules, the plans “will all be in the same format, so you can easily compare categories of coverage, cost sharing, provider networks, deductibles and co-payments — all the things people care about.”

The improvements in coverage are expected to drive up the cost of premiums by at least 10 to 13 percent, according to a Congressional Budget Office estimate. But the changes will provide a transparency that is not available today, Ms. Tolbert said, adding, “This really arms consumers and gives them a lot more power in the market than they have now.”

Though all the plans must provide the same essential package of benefits, consumers will be able to choose from four different levels of color-coded coverage — platinum (which will pay 90 percent of the cost of services), gold (80 percent), silver (70 percent) or bronze (60 percent). Young adults can opt for even less coverage. Policies will be priced accordingly.

Another standardized component is a cap on out-of-pocket costs: after patients reach that limit — $5,950 a year for an individual and $11,900 for a family, less for people with low incomes — the plans must cover 100 percent of additional costs.

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