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All health insurance plans are required by law to cover 10 essential health benefits
There are 10 essential benefits that all health insurance plans must cover, including preventive care, emergency care and prescription drugs
Most plans also have coverage related to birth control and breastfeeding
Insurers cannot deny you coverage or charge more just because you have a chronic condition
The Affordable Care Act, also known as the ACA or Obamacare, made it necessary for health insurance companies to cover certain healthcare services in all health insurance plans. These services are known as the 10 essential health benefits (sometimes referred to as EHBs). Insurance plans also cannot put an annual or lifetime limit on how much you spend on these services.
The 10 health benefits aren’t necessarily specific services; they’re more like categories of service. For example, one of the 10 benefits is emergency services. An emergency is generally a situation where there’s a risk of you losing your life or a limb unless you receive immediate medical care. But within the term “emergency services,” there is some leeway.
The 10 essential benefits are
Each state also sets a benchmark for the exact services a plan should cover within the 10 benefits, but the differences should be small. Still, it’s important to check your state’s exchange to see exactly what services to expect.
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All individual and small-group health insurance plans are required by law to cover the following 10 health benefits.
These benefits are general categories and represent the minimum coverage that a plan must offer. The specific services that an insurer covers within each category may vary slightly from state to state. Each state sets what is called a benchmark plan. The benchmark plan is the standard for what particular services all health insurance plans within a state should cover. So while plans in every state must cover the 10 essential health benefits, some states and require insurers to include additional specific services.
State, federal, and private exchanges will show you the exact services that each plan covers, so make sure to check before you apply for a plan.
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. In many cases, it also matters whether you have an HMO, PPO, or EPO.
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.
However, many plans still require you to pay some money out of pocket for prescription medicine, usually through a copay.
Learn more about prescription drug coverage.
Children under the age of 19 can get a variety of health care services, including a variety of dental and vision services. They can get two annual teeth cleanings and other necessary orthodontic care. Children can also get 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.
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.
You can find a list of preventive care services through the healthcare.gov website.
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 also require you to see a specialist physician.
Health insurance can help pay for your medical expenses.
Health insurance coverage pays for medical expenses you can't afford out of pocket.
Under the Affordable Care Act, an insurance company can’t charge you more or deny emergency care. They also cannot require you to receive pre-authorization in order to get emergency care.
However, it’s important for you to understand how your individual plan defines emergency services. In many cases you 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 totalling thousands of dollars.
Additionally, your insurance may also cover your care only to the point where your health is stable, and then you have to cover other costs you incur. At that point, using an out-of-network hospital or doctor can potentially add $5,000 or more to you medical bill. If you got to the hospital via an ambulance but your insurance deems you could have gotten tot he hospital through other means, it’s possible you’re on the hook to pay for the ambulance ride.
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.
Health plans must cover mental health services and behavioral health services. 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.
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 services like 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.
Learn more about getting disability insurance with a pre-existing condition to protect yourself from the risk of losing your income.
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, and so it must be covered.) Insurance companies also cannot deny coverage or charge women more.
After you give birth, your insurance must also allow you to add yout it’s also possible 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.
Health insurance and life insurance work together to offer financial protection.
Health insurance can pay your medical expenses. Life insurance keeps your loved ones whole after you die.
In addition the the 10 categories of health benefits listed above, plans must also include a few other benefits.
All plans that you can buy through the health insurance marketplace must cover contraceptive methods and counseling for all women. Plans also 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
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.
No health insurance plan 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.
Policygenius’ editorial content is not written by a certified financial planner or advisor. It’s intended for informational purposes only and should not be considered legal, financial, or investment advice. Consult a professional to learn what financial products are right for you.
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