10 Essential Health Benefits Included With Every Health Insurance Plan
Every Affordable Care Act (ACA) health insurance plan must, at a minimum, cover 10 essential health benefits. That means these ACA plans — also called marketplace plans — are required to cover some or all of the cost of certain health care services.
Translation: If you have marketplace insurance, you’ll pay less for these medical services (and potentially more, depending on your plan). Here, we break down the 10 essential health benefits and what they mean.
The 10 essential health benefits included with every health insurance plan
These are broad categories, and depending on what 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 insurance plan 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 and substance abuse care: Your plan includes coverage for your emotional and psychological wellbeing, 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.
Pediatric services, including oral and vision care: If children are included on your health plan, your insurance 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 outpatient care services, 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 marketplace 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 but are switching jobs and need marketplace insurance, understanding the details of marketplace coverage might feel 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 marketplace plans are highly regulated, they’re required to cover the 10 essential health benefits outlined above. Your employer-sponsored plan may have covered these 10 benefits, but if it wasn’t required to cover all of them, some 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 insurance 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.
How do I get coverage?
If you don’t have coverage or want to transition out of your current insurance onto a marketplace plan, Stride can help. Unlike confusing government sites, Stride’s customizable search tool makes it fast and simple to find the right plan for your needs at the best possible price. Anyone can get a plan during the annual Open Enrollment for health insurance, which runs from Nov. 1 to Jan. 15 in most states. You may also qualify to get coverage outside of the Open Enrollment window if you experience a big life change.
Ready to find your plan? Enter your ZIP code below to get your personalized plan recommendations in less than five minutes.
