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Health plans fall short of feds' law

| Thursday, March 7, 2013, 8:48 p.m.

WASHINGTON — Just 2 percent of health plans available to consumers in the private insurance market offer all the coverage that will become mandatory next year under the federal health care law, a new analysis has found.

Only about one in 50 plans now complies with the main requirements of the Patient Protection and Affordable Care Act, according to HealthPocket Inc., a Sunnyvale, Calif., technology firm that “compares and ranks” health plans.

Consumers and the federal government might end up paying the cost of the new requirements through higher premiums.

The analysis found that basic benefits, including doctor visits, emergency room care, hospitalizations and lab tests, were standard offerings for nearly all the 11,000 plans in the study.

But only 1 in 4 offered pediatric care, and only 8 percent covered dental checkups for children. About one-third covered maternity and newborn care, and just over half covered services to deal with substance abuse.

Those and other coverage areas are considered “essential health benefits” under the health care law. All health insurance plans in the individual and small-business market must offer them beginning next year.

But “we couldn't find a single plan that had every feature fully satisfied,” said Kev Coleman, head of research and content at HealthPocket.

Unless a health plan is exempted from the health care law's requirements, “it will have to change to survive,” Coleman 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.”

The law requires that health plans offered to individuals and small employers provide coverage in 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Massachusetts health plans, on average, offered more than most plans across the country, the analysis showed. The Obama administration has often cited that state's health insurance program as the model for its initiative.

Massachusetts insurance plans covered 94 percent of the essential benefits, on average, followed closely by Rhode Island's, which provided about 93 percent. Hawaii plans covered 90 percent of mandatory benefits and plans in California, Maryland and Vermont covered 89 percent.

Alaska plans had the worst showing, covering only 66 percent of essential benefits. They were followed by Wisconsin at 67 percent and Texas and New Hampshire at 68 percent.

The insurance industry said the new requirement would raise the cost of coverage.

“Anytime you add benefits to a policy, it adds to the cost of health care coverage,” said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a trade association for large insurers. “And many people will be getting coverage that's more comprehensive than they have today, but it will also be far more expensive than what they pay today.”

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