10 Essential [Mandated] Health Benefits (EBH)
under Health Care Reform, PPACA

What and how much is covered for #Lab – Laboratory Fees – as an essential benefit  under Health Care Reform?

• Is the $10 limit for most X-rays and laboratory test limited only to this Blue Shield Platinum plan?
  • ***I believe the co-pay would depend on what Metal Level, one has purchased.
• Are the words “most” and “encounter” defined anywhere?
  • ***Proactive Office Encounter is a Kaiser Term – Here’s an explanation… but I don’t find a simple definition.
  • I see that essential benefits include laboratory tests for PSA, cholesterol and diabetes are no charge items as they are deemed preventative care.
• ***Yes, but see the limitation for conditions that are already diagnosed!
• Our current Blue Shield of CA PPO small business plan took effect on July 1, 2011.  As I have previously explained, when I last had routine lab tests, which was in October, 2012, the cost was over $1,000 from an in-network provider.  So, since the Affordable Care Act has taken more full effect, is there any chance those lab tests which are now deemed preventative care and thus no charge,
  • ***I’m glad you’ve asked this question… I don’t think ANYONE knows of the limitation for what’s already been diagnosed.
  • will be no charge under our current plan, or will we have to wait until a new plan is in effect?
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• Office Visits
  • An Office Visit is when You go to a Physician’s office and have one or more of ONLY the following three services provided:
  • History-Gathering of information on an illness or injury.
  • Examination
  • Physician’s medical decision regarding the diagnosis and treatment plan.
  • Office Visit will not include any other services while at the office of a Physician (e.g., any surgery, Infusion Therapy, diagnostic X-ray, laboratory, pathology and radiology) or any services performed other than the three services specifically listed above.
  • Covered Services include:
  • Office Visits with Primary care Physicians and Providers (PCP) and Specialty Care Physicians and Providers
  • Home Visits for medical care to examine, diagnose, and treat an illness or injury.
  • Note:  Physician visits in the home are different than the “Home Care Services” benefit described earlier in this Agreement (Page 88)
• benchmark.Kaiser Small Group HMO
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• One might also consider these options for fees that don’t get paid
  • health-savings-accounts-hsa/
  • Section 105  medical_expense_reimbursement_plans_section_105.

#Clinical Trials are Covered under Health Care Reform