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Just one in 50 health plans meets ACA benefits requirements

Only 25% of private health plans cover pediatric care, report finds

Topics: Access to Care, Quality, Performance Improvement, Appropriateness, Service, Reimbursement, Finance

March 11, 2013

Just one out of every 50 health plans in the private insurance market currently meets the minimum coverage or essential health benefit standards that will be required in 2014 under the Affordable Care Act (ACA), according to a new HealthPocket analysis.

Most of the 11,000 plans analyzed covered physician visits, ED care, hospitalizations, and laboratory testing. However, plans lacked coverage in others areas that will be required by the ACA, such as:

  • Pediatric care, covered by only 25% of plans;
  • Dental checkups for children, covered by 8%;
  • Maternity and newborn care, covered by about 33%; and
  • Substance use disorder treatment, covered by slightly more than 50% of plans.

The states with plans covering the most of the ACA's essential benefits were:

  • Massachusetts (an average of 94% of essential benefits covered);
  • Rhode Island (93%); Hawaii, (90%);
  • California (89%);
  • Maryland (89%); and
  • Vermont (89%).

The states with plans covering the fewest essential benefits were:

  • Alaska (an average of 66% included);
  • Wisconsin (67%);
  • Texas (68%); and
  • New Hampshire (68%).

Kev Coleman, head of research and content at HealthPocket, said, "Consumers will be entitled to more health benefits in 2014 than ever before, and this will require existing health plans to expand coverage or close and be replaced by entirely new plan designs" (Pugh, Miami Herald, 3/7).

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