The Affordable Care Act, also known as the ACA or Obamacare, allows you to buy individual and small group (small business) health insurance plans through an ACA marketplace (also called an exchange). All qualified health insurance plans sold through the Obamacare marketplace must cover the 10 essential health benefits.
Essential health benefits (sometimes called EHBs) are general categories of service and they represent the minimum coverage that a plan must offer. However, within each category, there is leeway and specific services or treatments may or may not be covered depending on your exact situation. Services covered also vary slightly from state to state because each state is allowed to set its own benchmark plan. A state’s benchmark plan represents the exact services all plans must cover to be sold on the state’s exchange.
The 10 categories of essential health benefits are
Ambulatory patient services (outpatient care)
Pediatric services (including dental and vision coverage)
Hospitalization for surgery, overnight stays, and other conditions
Mental health coverage and substance use disorder services
Rehabilitative and habilitative services
Pregnancy, maternity, and newborn care
You can check a plan's exact details during open enrollment. Also remember that these benefits only apply to Obamacare plans, and may not be covered by other types of health insurance, like plans from large employers, Medicare, or Medicaid (they are often covered, though).
What it means for a service to be covered
Two important points to understand are that not all services within a category need to be covered, and that having a service covered does not necessarily mean your insurance will pay the full cost of that service.
First of all, exchange plans all need to cover at least one service within each of the 10 EHB categories. Not all services or treatments within an EHB category will necessarily be covered by your plan, though. And since states are allowed to set their own minimum coverage, Obamacare plans vary from one place to the next.
Secondly, having a “covered” benefit doesn’t necessarily mean don’t pay for care; it simply means you cannot be denied care. An insurance company must include covered benefits in their cost-sharing, so you will probably still pay something. For example, if your plan covers ambulance rides, it doesn’t mean all ambulance rides are free. They’re covered only in certain situations and you will still have to pay some of the cost. Using an out-of-network ambulance may not be covered and you could end up owing the full cost. At the same time, insurance companies cannot put annual or lifetime limits on how much you spend on any of the essential health benefits.
For more on the basics of health insurance, start with our guide to health insurance basics.
The cost of covered services
How much you pay for a covered service depends on multiple factors. On a basic level, your plan's metal tier determines the proportion of costs your insurance company will require you to pay for in-network care.
The type of plan you have — HMO, PPO, or EPO — will also help determine your in-network and out-of-network costs. For example, seeing a specialist without first going to your primary care physician will likely cost you more if you have an HMO. In general, you may have to pay most or all of the costs for receiving care outside of your service network — even if that same service would have been free from an in-network provider.
Finally, your costs will also vary based on whether or not you’ve already spent enough to reach your deductible — after which your insurance starts to cover some costs — and whether or not you’ve hit your out-of-pocket maximum — after which your insurance covers all costs for the remainder of the calendar year.
See our study on where Obamacare plans cost the most.
A breakdown of all 10 essential health benefits
All individual health insurance plans and small group (small business) plans sold through an Obamacare exchange must cover these 10 essential health benefits:
Outpatient care (ambulatory services)
Pediatric care (including dental and vision coverage)
Mental health coverage
Rehabilitative and habilitative services
Pregnancy, maternity, and newborn care
For more on COVID-19, read our article on how health insurance covers the coronavirus.
1. Outpatient care
Technically called ambulatory patient services, this is any care you receive without going to a hospital. This is the most common type of health care that most people use. For example, if you have a cold, visit your doctor’s office, and the doctor treats you for the cold, that’s outpatient care.
Outpatient care also includes relatively small medical procedures like X-rays and mammograms.
Your insurance doesn’t have to cover the full cost of outpatient care, but the law does require that you have access to a sufficiently large network of doctors and health care providers. How much you pay for visiting a doctor will vary by location and by plan.
2. Prescription drugs
All individual and small-group health plans cover at least one drug in each category and class listed in the United States Pharmacopeia (USP). The USP is a collection of information on prescription, over-the-counter, and other drugs. It’s run by a nonprofit organization that sets the standards for which drugs and medicines are approved for use. What this means for you is that you should have access to at least one drug option when you need prescription medication.
Learn more about prescription drug coverage.
3. Pediatric care
Children under the age of 19 can get health care services through an exchange plan, including a variety of dental and vision services. They can get two annual teeth cleanings, other necessary orthodontic care, an annual eye exam, and either glasses or contacts.
Health insurance plans are not required to cover dental or vision services for adults, even though they have to cover it for children. If you need dental and vision care and your health insurance policy doesn't offer it, look into purchasing a supplemental health insurance plan.
4. Preventive care
All insurance companies must cover preventive care, like regular checkups with your primary care physician. Preventive care also includes health screenings, such as a Pap smear or prostate exam. You may hear this type of care referred to as wellness services. Insurers must also cover treatment and management of a chronic disease.
Learn more in our guide to preventive care services.
5. Laboratory services
Your insurance plan must cover lab services beyond just preventive screening tests. In many cases, you will hear this referred to as a diagnostic test. Getting one of these tests done could require you to see a specialist physician. In some cases, the cost to see a specialist is only covered if you are referred by your primary care doctor.
6. Emergency services
Under the Affordable Care Act, an insurance company can’t deny you emergency care, charge higher prices for emergency care, or require you to receive pre-authorization. Emergency care is one of the most costly medical expenses and certain situations can cost a lot even if you have insurance, so it’s very important for you to understand how your individual plan defines emergency services.
In many cases, your insurance will cover care for a life-threatening situation and for situations where you could lose a limb without immediate medical attention. If you go to the emergency room but your circumstances don’t meet the exact definition of an emergency, you could end up with medical bills totaling thousands of dollars.
Additionally, your insurance may cover your care only to the point where your health is stable, and then you have to cover other remaining costs you incur (even though doctors may still require you to stay in the hospital). At that point, using an out-of-network hospital or doctor can potentially add $5,000 or more to your medical bill. If you went to the hospital via an ambulance but your insurance deems you could have gotten to the hospital through other means, it’s possible you’d be on the hook to pay for the ambulance ride.
Related article: How emergency rooms work.
All insurance plans must cover your hospitalization. That includes surgery, overnight stays, and other care you receive. The big caveat is that your insurer doesn’t always have to cover the entire bill from hospitalization. Hospital stays can realistically cost more than $10,000 (including room and board as well as your actual care), so be prepared for a potentially hefty bill if you haven’t hit your deductible or out-of-pocket limit yet.
Read more: What are out-of-pocket expenses?
8. Mental health coverage
A health plan must cover mental health services and behavioral health treatment under the Affordable Care Act. This could include seeing a psychologist or receiving treatments for substance abuse and rehabilitation. You may still have to pay a copay and your plan may also limit coverage for therapists to a certain number of visits per year. For more, see our article on how to learn if your insurance plan covers mental health treatment.
9. Rehabilitative and habilitative services
Rehabilitative services cover services, treatment, and medical equipment that help you recover your mental and physical skills after an injury, disability, or the onset of a chronic condition. Examples of covered equipment are walkers and wheelchairs.
Habilitative services are types of care that help you keep, gain, or improve skills that are necessary for your day-to-day life. This can include physical therapy, occupational therapy, or speech-language pathology. Individuals living with a disability or chronic disease also receive coverage through this category of care, but that doesn’t mean insurers have to cover medical bills in their entirety.
Make sure you’re covered in case of an accident with disability insurance.
10. Pregnancy, maternity, and newborn care
Insurance companies must cover care during pregnancy, as well as before and after childbirth. Prenatal care is included as a preventive care service, so insurers cannot charge you extra for it. Maternity care and newborn care must also be covered.
If you are pregnant before you get a policy, your insurance company is still required to cover the services mentioned above. (Pregnancy is considered in the same category as pre-existing conditions, so it is covered by Obamacare plans.) Insurance companies also cannot deny coverage or charge women higher prices.
After you give birth, your insurance must allow you to add your child to your plan. You can also change to a different plan from the marketplace. (Childbirth is a qualifying life event, which means you can enroll for a plan at any time of the year via special enrollment.)
Read more on how to choose the best insurance for pregnancy.
Other benefits a plan must cover
In addition the 10 categories of health benefits listed above, plans must also include a few other benefits.
Birth control coverage
All plans that you can buy through the health insurance marketplace must cover contraceptive methods and counseling for all women. Plans cannot charge a copay or coinsurance for you to get contraception, as long as you get it from an in-network provider.
Covered contraceptive options include
Birth control pills, vaginal rings, and other hormonal birth control
Diaphragms, sponges, and other barrier methods of birth control
Intrauterine devices (IUDs) and other implanted devices
Plan B and emergency contraception
Education and counseling services
Plans do not need to cover drugs that induce abortions or services that affect male reproductive capacity, like a vasectomy.
If you get health insurance through an employer-sponsored plan, the plan also has to cover contraception. The exception is that the health plans from some religious organizations and some employers with a moral objection to contraception do not have to offer it to employees.
Learn more about birth control coverage in health insurance.
Most insurance plans have to provide breastfeeding support and counseling. They must also cover the cost of breastfeeding equipment, including a breast pump (either a new one or a rented one). Your insurance may provide these services before birth, after birth, or both.
Coverage for pre-existing conditions
Under Obamacare, no health insurance plan sold through an exchange can deny you coverage or charge you more because you have a pre-existing condition. A pre-existing condition is any health problem you had before the beginning of your insurance coverage. Examples include asthma, diabetes, and cancer. Starting on the first day of your coverage, the insurer also cannot refuse to cover your treatment for a pre-existing condition.