10 Essential Health Benefits Every Plan Must Cover
The Affordable Care Act, also known as ACA or Obamacare, mandated that every health insurance plan must cover broad “essential” categories of services. For example, doctors’ appointments, prescription drug coverage, mental health services, and more. These general healthcare services are known as the 10 essential benefits or EHBs. Under the current law, insurance companies can not put annual or lifetime dollar limits on these services and must equal the scope of benefits typically covered by employers as shown by a Department of Labor survey of employer-sponsored coverage. Before ACA, many plans did set annual and lifetime limits on services, and required you to pay the cost of all care exceeding those limits. While all qualified plans must offer these benefits, the scope and quantity of services offered under each category vary based on your state’s requirements.
- Outpatient Care, or Ambulatory patient services – outpatient care is a broad category that includes services you receive without going to a hospital. For example, wellness and prevention doctors’ appointments, diagnostic services, treatments, and rehabilitation.
- Emergency Services – Under the Affordable Care Act, insurance companies can not:
- charge more for emergency care at an out-of-network hospital
- require prior approval before receiving emergency room services from a provider or hospital outside your plan’s network
- Hospitalization – insurance plans are required to cover hospitalization, such as overnight stays and surgeries. This does not mean that your plan will cover the entire hospital bill, however. The average hospital stay costs over $10,000 so the amount you owe will depend on your plan’s co-payment, deductible, or co-insurance.
- Pregnancy, Maternity, and Newborn Care – qualified health plans must cover these categories both before and after birth. Insurance companies cannot deny coverage or charge women more.
- Mental Health and Substance Abuse services – Pre-existing mental and behavioral health conditions must be covered, including behavioral health treatment such as counseling and psychotherapy. Insurance plan copays will apply.
- Prescription Drugs – Under the health care law, at least one prescription drug must be covered for each category and classification of federally approved drugs. Limitations do apply.
- Rehabilitative and habilitative services and devices – Health plans must cover services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills. Examples include physical therapy or wheelchairs.
- Laboratory services – qualified insurance plans must cover lab services that help a doctor diagnose an injury, illness, condition, or monitor the effectiveness of treatment.
- Preventive and wellness services and chronic disease management – this includes services such as immunizations, screenings, physicals, and counseling.
- Pediatric services – include well-child visits, immunizations, oral and vision care (adult dental and vision coverage are not essential health benefits)
Health Insurance Questions?
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