What are the ten essential health benefits?

The ACA defines 10 categories of service that health insurance plans must cover.  These include doctors’ service, inpatient and outpatient hospital care, prescriptions drug care, pregnancy, and more.  Additionally, plans must offer dental to children, but the dental benefits for adults are optional.

 

These covered categories do not just apply to Marketplace plans, but to ALL small group and individual health insurance plans.  There are some plans still offered that were started before 2014.  These plans are considered grandfathered and may not cover all of these 10 essential health benefits.

 

Specific services do vary a little based on your state’s own requirements, and you’ll see exactly what each plan offers when you compare plans side by side.

1) Emergency Care

Prior to the ACA, when you were admitted to the ER, you ran the gamble of having your visit denied by the insurance company.  They could come back and say that you were not in a seriously enough life-threatening condition, and that they would not pay.

 

Now, you do not need prior authorization to be admitted to the ER.  Additionally, health plans now reimburse emergency department visits without having to fight the insurance company.

2) Habilitative Services

Rehab focuses on regaining lost function, while habilitation helps develop skills never fully acquired.  This includes physical, occupational, and speech therapy.

3) Newborn Care

Both maternity care and newborn care are essential health benefits and will be covered.  This applies to services provided before and after your child is born.

4) Prescription Drugs

Access to necessary medications is critical for health.  At least one medication per drug class, including insulin, is covered.  All drug coverage is also based off of formularies, to offer different options to find affordable drug, so as brand name vs generic.

5) Ambulatory Patient Services

Ambulatory refers to outpatient and office visits.  Services include procedures and test not requiring overnight hospital admission.  These range from minor treatments like flue shots to MRI scans diagnosing complex conditions.

6) Behavioral Health Treatment

This encompasses a broad range of conditions that affect a person’s behavior.  Substance abuse, eating disorders, and autism all fall under the category of behavioral health.

 

Often, mental health disorders are treated with medication and therapy, while behavioral health disorders may require a more comprehensive approach that addresses social and environmental factors.

 

When looking at behavioral health and mental health side by side, it is easiest to consider that behavioral health is the group, and mental health is a subset inside that group.

7) Mental Health & Substance Use Disorder Services

Care for psychiatric issues like depression & anxiety fall under essential benefits.  So do substance abuse disorders.  Both outpatients counseling and inpatient treatment qualify when considered medically necessary.

8) Pediatric Services

Child beneficiaries through age 21 should undergo developmental assessments, immunizations, preventative counseling, and medical treatments without additional fees.

9) Laboratory Services

Labs can be performed for a variety of reasons, from information gathering to prevention, to chronic condition management.  Routine bloodwork, culture testing, and genetic screens all fall under this category.

10) Wellness and Prevention Services

Health plans must cost a set of preventative services, like shots and screening test, at no cost to you.  There are different services offered for women, children, and all adults.

Additional Benefits

All plans include birth control coverage with no copayment or coinsurance when provided by an in-network provider.  Covered contraceptive include birth control pills, Plan B, education & counseling, and implanted devices such as an IUD.

 

All plans must also provide breast feeding coverage.  This includes support, counseling, and equipment for the duration of breastfeeding.

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