A young patient at South Central Family Health Center in South Los Angeles. Fewer than one in five health insurance plans in the U.S. were found to cover pediatric care in a recent analysis by HealthPocket.
A comparison of more than 11,000 health insurance plans found that fewer than 2 percent are ready to meet minimum coverage standards that will go into effect in 2014 under the Affordable Care Act.
Those minimum coverage standards are known as "essential health benefits," which every U.S. health insurance plan must cover starting next year. HealthPocket, a company that ranks and compares plans, used these benefits as a gauge in its analysis of whether insurers nationwide are ready to meet the new standards.
The verdict? If the Affordable Care Act's essential health benefits requirement went into effect today, more than 98 percent of health plans would be in big trouble.
On average, U.S. health plans cover 76 percent of essential health benefits. (That includes partial or limited coverage.) California did better than that – health plans in the Golden State covered, on average, 89 percent of essential health benefits. That wasn't as good as No. 1-ranked Massachusetts, where the average is 94 percent, but it was way better than No. 50-ranked Alaska, where the average is just 66 percent.
Health insurance companies are doing pretty well with five of the essential health benefits laid out by the Obama Administration (Note: All percentages refer to plans that offer at least partial coverage):
- 100 percent of plans cover emergency and urgent care services.
- 100 percent of plans cover hospitalization services.
- 100 percent of plans cover preventive care, wellness and chronic disease management services – that means routine physicals, checkups, vaccines and care for conditions like diabetes.
- 99 percent of plans cover ambulatory (outpatient) care.
- 99 percent of plans cover lab tests – that is, diagnostic tests or imaging services.
For other benefits, coverage isn't great, but the number of insurers covering them doesn't fall below 50 percent:
- 85 percent of plans cover rehabilitation and habilitation services – those are the services required by a patient who needs to relearn or acquire a skill that's been impaired by a medical condition.
- 82 percent of plans cover the cost of prescription drugs.
- 61 percent of plans cover the evaluation and treatment of mental health issues.
- 54 percent of plans cover substance use disorder services, which address alcohol and drug dependencies.
And then there are the problem areas:
- 34 percent of plans cover maternity and newborn care – that means prenatal, delivery and postnatal services.
- 24 percent of plans cover pediatric care, which includes vision and dental care.
A different group of experts recently pointed to the current shortcomings in coverage of women's health care, and called upon state policymakers to account for those in their planning of statewide health insurance marketplaces, which will open for enrollment in October.
HealthPocket said the study's findings raise the question of "whether the coverage expansion required by the [Affordable Care Act] will cause premiums to rise in 2014," since insurance companies will need to find a way to cover the cost of fully meeting federal minimum coverage requirements.
State lawmakers may also implement broader minimum requirements that go beyond federal guidelines and that apply only to insurance providers in their state.