Understanding the Standard Benefits in a Health Insurance Policy

Shopping for health insurance can be overwhelming. While there are hundreds of choices, including deductible amounts, networks and out-of-pocket limits, certain components are standard among all California health plans.

Regardless of whether you choose a high-deductible major medical insurance policy or a comprehensive health plan, you can expect at least some of the same benefits between all providers.

Contraception and Women’s Health Care

The Affordable Care Act requires health insurance companies to provide comprehensive preventive health benefits to women without cost sharing. Beginning in August 2012, the U.S. Department of Health and Human Services interprets that to include contraceptive methods approved by the FDA.

In other words, all new health insurance plans purchased individually or through an employer’s group plan in California will provide 100 percent coverage for prescription birth control without requiring a prescription co-pay, deductible or co-insurance. Up until August 2012, California insurance codes still mandate that all insurance providers with policies that cover prescription drugs also provide benefits for prescription contraceptive methods as well.

In addition to contraception, the Affordable Care Act requires similar no-cost benefits for women that include routine gynecological screenings, such as HPV testing and screening for gestational diabetes. Annual well-woman visits are also covered, as are mammograms for women over age 40.

Preventive Health Care

California’s Senate passed a law that aligns with federal laws requiring certain preventive care services to be available to all California health insurance policy holders. For example, annual wellness visits are standard for all Americans, regardless of age, and children are subject to no-cost well-child visits, vaccinations and screenings. All California health plans must also cover recommended colonoscopy, cholesterol screenings, blood pressure screenings, diabetes screenings and flu shots without charging a co-pay or out-of-pocket cost.

Maternity Insurance Coverage

On October 6, 2011, Governor Jerry Brown signed legislation requiring insurance providers to include maternity benefits in both individual and employer-based health plans. The law goes into effect July 2012, and will extend benefits to millions of women who do not have maternity coverage through an employer’s group health plan. Until now, only federal HIPAA regulations have affected maternity benefits, requiring employers to provide maternity benefits.

Counseling

Preventive care is not effective if individuals don’t know how to use it. To that end, California health insurers now provide complete counseling benefits. Policy holders who participate in covered counseling sessions may do so without cost sharing responsibilities. Examples of covered counseling services include those that provide advice for smoking cessation, healthy pregnancies, necessary weight loss, treating addictions and eating a more nutritionally health diet. The coverage also provides benefits for Californians struggling with depression.

Long-Term Dependent Coverage

All California health insurance plans either already, or will soon, provide long-term dependent health care coverage. When Congress passed health insurance reform in 2010, new laws paved the way for children to remain on a parent’s health insurance policy until age 26, rather than upon completion of college or at an earlier age. In California, legislation passed by the state Senate mirrors those requirements.

Until 2014, all insurers must allow adult dependents coverage so long as the adult dependents do not already have access to health insurance through an employer. However, in 2014, adult dependents will have the choice of remaining on a parent’s policy or otherwise choosing an employer or private policy.

No Limits

Right now, no new or renewed California health insurance plan is allowed to legally impose a lifetime limit on benefits. That means that insured individuals cannot max out benefits due to a serious illness. However, health insurance companies are allowed to impose annual limits on coverage. Until September 2012, annual limits must be at least $1.45 million, after which time the annual limits must increase to at least $2 million. By 2014, insurance companies can impose neither a lifetime, nor an annual limit on policy holder benefits.

Guaranteed Issue Coverage

All California health plans have guaranteed issue coverage that ensures no health insurance company can drop a person from a plan or cancel coverage due to illness or frequent use. The only conditions that allow insurers to rescind coverage are those that involve fraud.

Further, all California health insurance companies must provide automatic and guaranteed approval for children applying for health insurance, regardless of pre-existing conditions. By 2014, the same conditions will apply to adults as well, requiring insurers to cover all applicants, regardless of health history.

Right to Appeals

Health laws make it possible for insurance policy holders and applicants to appeal a health insurance company’s decision to deny payment for a particular service or to deny coverage to an applicant for any reason. Each insurance company must have an internal appeals process. If an appeal receives a second denial, an independent third-party appeal review is available to policy holders.