Essential health benefits and preventive care in Arizona

Essential health benefits are the ten categories of care that every individual and small group ACA plan must cover, whether you buy it on HealthCare.gov or directly from an insurer licensed in Arizona. They include emergency care, hospital stays, prescriptions, maternity care, mental health care and preventive services. On top of that, a long list of preventive services must be covered with no copay or coinsurance when you use a network provider, even before you meet your deductible. Knowing this list helps you use the coverage you already pay for.

The ten essential health benefits

Plans may add more, but they cannot cover less. Plans also cannot put annual or lifetime dollar limits on these benefits. Each state sets a benchmark plan that defines the details, so the exact list of covered drugs or therapy visits can differ from one plan to the next.

In Arizona, the benchmark plan chosen by the state sets the detailed list for individual and small group plans. That is why two Arizona plans may both cover physical therapy, for example, but with different visit limits. The Summary of Benefits and Coverage for each plan shows those limits in plain language.

• Ambulatory patient services: outpatient care you get without being admitted to a hospital.
• Emergency services.
• Hospitalization, including surgery and overnight stays.
• Pregnancy, maternity and newborn care, before and after birth.
• Mental health and substance use disorder services, including counseling and psychotherapy.
• Prescription drugs.
• Rehabilitative and habilitative services and devices, which help people recover or gain skills after an injury, disability or chronic condition.
• Laboratory services.
• Preventive and wellness services and chronic disease management.
• Pediatric services, including dental and vision care for children.

Preventive care with no copay

ACA plans must cover a set of preventive services without charging a copay or coinsurance, even if you have not met your deductible, as long as you use a provider in the plan's network. For adults, HealthCare.gov lists services such as these:

Children have their own list of covered preventive services, including well-child visits, recommended vaccines, vision screening and developmental screenings, so keep their checkups on the calendar too.

• Blood pressure screening for all adults.
• Cholesterol screening for adults of certain ages or at higher risk.
• Colorectal cancer screening for adults 45 to 75.
• Depression screening.
• Type 2 diabetes screening for adults 40 to 70 who are overweight or obese.
• Hepatitis B, hepatitis C and HIV screening for people in the recommended groups.
• Recommended vaccines, such as flu shots.
• Tobacco use screening and help to quit.
• Additional services for women, including well-woman visits and certain cancer screenings, and for children, including well-child visits.

The fine print that trips people up

The word free applies to the preventive service itself, not to everything that happens in the same appointment. If your doctor finds something during a screening and treats it, or you raise a separate problem during your annual physical, that part of the visit can be billed as diagnostic care and go toward your deductible.

A screening colonoscopy is a common example. The screening is preventive. If a polyp is removed, many plans still treat it as part of the screening, but billing rules vary. Ask the office how the visit will be coded before you go.

• Use an in-network provider. Out-of-network preventive care is not guaranteed to be covered at no cost.
• Book preventive visits as preventive visits, and save other concerns for a separate appointment if cost matters.
• Ask whether lab work will be sent to an in-network lab.

Your Summary of Benefits and Coverage

Every ACA plan must give you a Summary of Benefits and Coverage. It uses the same format for every plan, so you can compare them side by side, and it includes coverage examples for situations such as having a baby or managing type 2 diabetes. You can find it on each plan's page on HealthCare.gov or ask the insurer for a copy at any time, along with a uniform glossary of insurance terms.

If a claim is denied and you believe it should have been covered, you have the right to an internal appeal and then an external review. In Arizona, the Department of Insurance and Financial Institutions oversees insurers licensed in the state and handles consumer complaints.

Keep a copy of the summary for your current plan somewhere easy to find, so you can check it before an appointment rather than after a bill arrives.

What is not an essential health benefit

Adult dental and vision care are not essential health benefits, so most medical plans do not include them for adults. Long-term custodial care, such as help with bathing and dressing at home or in a care facility, is not covered either. Those gaps are why standalone dental, vision and long-term care coverage exist.

Short-term medical plans are not required to cover the essential health benefits at all. They often leave out maternity care, mental health care and prescriptions, so read the policy carefully before you rely on one.

Mental health care deserves a special mention, because it is covered but underused. Counseling and therapy are essential health benefits, and federal parity rules generally mean plans cannot make mental health coverage more restrictive than medical coverage. Many plans also cover telehealth visits for therapy, which makes it easier to fit care into a busy week.

How to use your preventive benefits this year

Many people in the East Valley pay premiums all year and never use the preventive care they are entitled to. Preventive visits are also the easiest way to build a relationship with a primary care doctor before you need one, which matters when an HMO or EPO plan requires a doctor to coordinate your care.

• Book an annual physical or well-woman visit with an in-network primary care doctor.
• Ask which screenings are recommended for your age and history, and whether each will be billed as preventive.
• Get your recommended vaccines at an in-network pharmacy or office.
• Use well-child visits for children, which include developmental and vision screenings.
• Keep your Summary of Benefits and Coverage handy so you know what costs what.

Prescription drugs: the benefit people check last and need first

Prescription drugs are an essential health benefit, but every plan has its own drug list, called a formulary, organized into tiers. The same medication can cost very different amounts on two plans with the same premium. Some drugs need prior authorization or step therapy, which means the plan wants you to try another drug first.

Before you choose a plan, enter every prescription with its dose in the HealthCare.gov plan comparison tool or ask us to check it for you. Then look at what tier it sits on and whether your deductible applies to it. That one step prevents most of the January surprises we see.

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The bottom line

You are already paying for preventive care, so use it, and know where your plan stops. Visit our Individual and Family Health page to compare plans, and call Viola if you want help reading a Summary of Benefits and Coverage. Education first: she makes sure you know what you have, how to use it, and what it covers.