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10 Essential Health Benefits

The Affordable Care Act (ACA) requires all health insurance plans in the individual and small group markets to offer a certain set of Essential Health Benefits. This requirement would apply to all new plans as of January 1, 2014, both on and off the exchange.

Essential health benefits include:

  1. Ambulatory patient services: This common form of health care includes all outpatient services that you receive without admission to a hospital, such as walking into your GP’s office for a checkup. Almost all carriers provide this coverage, but details vary from plan to plan.

  2. Emergency services: When you go to the emergency room for urgent situations or conditions, this service is provided under most health plans. Plus, you cannot be charged extra for an out-of-network visit.

  3. Hospitalization: Your insurance must cover hospitalization, which includes inpatient care such as surgery and overnight stays in the hospital. Unfortunately, even with coverage, hospital bills can soar depending on how long someone requires these services.

  4. Maternity and newborn care: Insurance must provide health coverage both before and after birth. This coverage means that prenatal care is considered a preventative service, which is provided at no additional cost. Plus, insurance will cover childbirth and infant care as well.

  5. Mental health and substance use disorder services: Although in some states coverage is limited, the ACA requires health insurance to cover mental health services, including behavioral health treatment. Some insurance gives patients a set number of therapy sessions per year.

  6. Prescription drugs: All plans must cover at least one drug from every category listed in the U.S. Pharmacopeia. Although in some instances, an out-of-pocket cap must be met initially.

  7. Rehabilitative and habilitative services and devices: Many plans cover services that assist you in gaining or recovering mental and physical skills after an injury, a disability or a chronic condition. This coverage also encompasses the use of medical equipment such as wheelchairs, braces and walkers.

  8. Laboratory services: This coverage differs depending on the type of service provided. Some screenings, like Pap smears or prostate exams, are covered as preventative. However, you may be billed for diagnostic tests ordered by your doctor to determine if you have a disease.

  9. Preventive and wellness services and chronic disease management: The idea behind this benefit is to get individuals to see their doctor before they get sick and medical bills start to rise. It includes many preventive services covered by your health insurance at no extra cost.

  10. Pediatric services: Beyond standard healthcare coverage, children under the age of 19 must be allowed basic dental and vision care. This benefit includes twice-yearly teeth cleanings, x-rays, fillings and even yearly eye exams, which covers a pair of glasses or a set of contact lenses.

Important to Know:

  • All Covered California plans have the 10 Essential Health Benefits.

  • The ACA banned annual or lifetime coverage caps on essential health benefits.

  • Preventive care, vaccinations and medical screenings cannot be subject to any cost-sharing when received in network.

  • Grandfathered plans, large group health plans and certain ERISA type plans are exempt from the Essential Health Benefit requirement.

  • States have the discretion to determine specific benefits they deem essential, so these can vary from state to state and even include additional services as a requirements.

  • Health Care Reform Plans offer many other benefits such as tax credits, guaranteed issue and cost-sharing reductions.

  • The Essential Health Benefits are not the same as Minimum Essential Coverage (MEC) which is the minimum type of insurance you must have in place in order to avoid the tax penalty.