10 Essential Health Benefits Included With Every Health Insurance Plan
Every Affordable Care Act (ACA) health insurance plan must, at a minimum, cover ten essential health benefits. These are broad categories, and depending in which state you live in, your plan may cover a different set of services in each category.
Laboratory services: This includes diagnostic lab tests and some preventive screening tests, like diabetes or cholesterol screenings.
Emergency services: Your insurer will help pay for emergency care at a hospital, even if you’re at a facility that’s out of your plan’s network.
Prescription drugs: Medications are categorized by tiers, and within each tier is at least one drug that your insurer has to help pay for. Keep in mind that similar medications may not be covered.
Mental health/substance abuse: Your plan includes coverage for your emotional and psychological well-being, including counseling, psychotherapy, mental health inpatient services, and even treatment for substance abuse.
Maternity and newborn care: This includes a variety of services that take care of you and your baby during pregnancy, delivery, and post-delivery.
Pediatrics services, including oral and vision care: If you have children included on your health plan, your insurer will help cover many services that keep them healthy. This includes routine dental checkups, yearly eye exams, vaccinations, and well-child visits.
Rehabilitative and habilitative services and devices: Designed for people with disabilities, injuries, or chronic conditions, this includes coverage for physical, occupational, and speech therapy visits.
Ambulatory patient services: These are services you get at outpatient care, which is medical care you get without being admitted to a hospital.
Preventive/wellness services and chronic disease management: Preventive services help you stay on top of your health, and are covered by all ACA plans. This means you can get certain cancer screenings, annual checkups, and much more at no cost.
Hospitalization: If you are in the hospital for inpatient care — which means you’re staying overnight — your plan will help pay for your medical bills. Keep in mind that your plan may only cover you for a certain period of time.
I Lost My Employer Coverage — What Should I Know About Essential Health Benefits?
If you’ve typically had employer-sponsored coverage and are new to the Marketplace and ACA plans, this might seem confusing or overwhelming. However, just think of essential health benefits as the basics that every plan must cover, just at different rates based on your plan’s metal tier.
Because ACA plans are highly regulated, they are required to cover the 10 essential health benefits outlined above. Your employer-sponsored plan may have covered these 10 benefits, but because it wasn’t required to, some of them may not have been included.
How Do I Find Out My Plan Details?
Your plan’s Summary of Benefits and Coverage (SBC) details everything your health plan covers. Contact your health plan provider for a copy of your SBC, or reach out to our team of specialists with any specific questions at 415-930-9110 or support@stridehealth.com.
Reminder: January 15th, 2024 is the deadline to enroll in health insurance for 2024. We can help you find the best plan for your specific needs, at the lowest possible price, in about 10 minutes or less. Enter your zip code below to get a free price quote.
