<p>I do have a question, for the experts here (I’m so in awe of what you guys have figured out.) I know that the ACA mandates maternity benefits–does that mean they cover the whole amount, or can it mean that the insured could have to pay a percent? My D who’s thinking kids in the near future is in open enrollment right now and wondering if she should pick a higher-priced, lower hospital-percentage-payment plan, or stay with her lower priced plan (employer-based.) anyone know what the mandate is on maternity? I’ve been googling, but can’t find an answer to what “mandated benefit” means.</p>
<p>Dstark, while it’s still expensive in NY it’s a bargain compared to what it was pre ACA. Prices for individual policies have come down about 50% in NY (including NYC.) They were so expensive before that only 17,000 people in all of New York State had an individual policy. </p>
<p>There’s something wrong with that article. People at those incomes are eligible for subsidies, which cap the out of pocket far lower than the percentages stated, which are apparently before-subsidies.</p>
<p>Maternity benefits must be covered, but they are not one of the free preventative treaments. So a pregnant woman can expect to have copays for her care. A woman who is pregnant should work out what she’d have to pay in premiums plus her part of the delivery costs for the different plans she is considering.</p>
<p>CF, "Busdriver, I’m reading the statute I posted in #3610 as saying that if a treatment counts as an essential health benefit, and if you are sent out of network because the in-network providers don’t treat that condition, you have to be charged for it just as if it was an in-network procedure.</p>
<p>So if you needed a kidney transplant, and you had to go out of network because your plan didn’t have any transplant surgeons, you would have to pay the same as you would have had to pay if it was in-network. Do you read the statute in a different way?"</p>
<p>I see the section E of the statute as only about emergency department services because of the AND in between (i) and (ii). “and if such services are provided out of network”, referring back to (i). To me, it doesn’t mention getting sent for any out of network services, or not having an in network provider.</p>
<p>Especially since one BCBS plan detail says this about emergency services:</p>
<p>If you need immediate medical attention:
Out-of-network payment at the in network level of benefits applies only to true medical emergencies and accidental injuries.</p>
<p>^^Seems like employer paid coverage would usually be the best option for someone who is only considering having kids, unless that plan is really bad. Seems better to save the money on premiums, at least someone else is sharing in the cost of it.</p>
<p>Emilybee… I know. There were only 17,000 people in individual plans in NY. 17,000!!! 2.6 million uninsured!!!</p>
<p>I like the charts. I dont want to have to keep looking for NY info. I could not sign up on the NY exchange or I should say wouldnt. I guess I am not ready to pull the trigger yet.</p>
<p>jbsmom, I see your point. So then what is preventing an insurer from setting up a plan with cheap in-network care, and NO providers in the network, so that they handle every single essential benefit by sending the patient out of network?</p>
<p>I think I posted earlier in the thread why the individual market was decimated years ago. NY went to community rate and guaranteed issue, and, as a result, most of the insurers promptly left the state. So you ended up with incredibly expensive insurance and many uninsured. Insurance in CA was much more affordable but unhealthy people couldn’t get it. Pick your poison.</p>
<p>One thing that I have been wondering that I dont think has been addressed. How does insurance work for those that go to med school or law school or somewhere where there is little to know income. In some areas, the insurance is close to free?
And is the insurance for the whole year or just the school year?</p>
<p>There are quite a few posters with kids going to med school. My guess is CC dies have kids going to law school.</p>
<p>The out-of-network, out-of-state has changed radically for Anthem. Today, you can seek elective treatment for any provider outside of Ca that accepts Blue Cross/Blue Shield. On Jan 1, this will be true only for emergency treatment.</p>
<p>Like every other state, most people got their insurance from their employer. The people who did not get their insurance from employers (could have a husband and wife only business) and had a preexisting condition did experience a problem in Ca. How many of them fell into this category is really not known. BTW, there was a time where you could get the insurance from the local chamber of commerce or other professional associations.</p>
<p>Busdriver—it’s employer sponsored either way. We were trying to figure out if she needed to go to higher premiums, or was maternity totally covered. looks like it’s not, so the higher premiiums might make sense.</p>
I guess I am not ready to pull the trigger yet.</p>