10 Essential Benefits Covered in the Health Insurance Marketplace

Prior to the Affordable Care Act, minimum standards health insurance mandates varied under discretion of each state. Many states did not require insurers to cover maternity care, mental health care, or prescription drugs. The Affordable Care Act introduced provisions that require all health insurers to cover 10 vital medical care services. Thus, allowing customers to compare different company insurance plans  with ease and confidence that their basic needs will be met.

These are the 10 essential benefits that the ACA requires health insurance plans to include:

1. Ambulatory patient services/Outpatient care—care received without being admitted to a hospital. Health insurance benefit designed to cover any out-patient services. This includes doctor office and clinic visits, same-day surgery, hospice treatment and other home health services.

2. Emergency services. Coverage of any unexpected injury or illness that could result in serious health impediments or death if not immediately treated. Transportation to an emergency room via ambulance will be covered, as well as receiving no penalty for out-of-network treatments without prior authorization.

3. Hospitalization—treatment in the hospital for inpatient care (i.e. surgery and overnight stays). During inpatient treatment, all services received must be covered, including; room and board, staff services, medications, tests, surgeries, transplant, medical procedures, certain nursing homes with medical care, etc..

4. Pregnancy, maternity, and newborn care—care before and after birth. All prenatal, labor, delivery, and newborn medical care is required to be covered.

5. Mental health and substance use disorder services—this includes behavioral health treatment, counseling, and psychotherapy. Substance abuse disorders and mental health disorders are covered for inpatient and outpatient individuals throughout diagnosis and treatment, i.e., counseling, psychotherapy, etc.. However, limits may vary according to state law.

6. Prescription drugs. Doctor prescribed medications will be covered by insurers, with a minimum of at least one medication in all categories. Applied limitations to this benefit includes not all prescription drugs are covered by insurers – some insurance companies may only cover generic versions of medications if offered.

7. Rehabilitation and habilitative services and devices to help people recover if injured, or have a disability or chronic condition—this includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more. Insurances provide coverage for rehabilitation and habilitation services and devices to aid recovery or development. Each year, providers must cover a minimum of 30 visits to physical or occupational therapy and 30 visits to cardiac or pulmonary treatment centers.

8. Laboratory services (i.e. lab tests). Diagnosis and monitoring tests for any medical condition must be covered. Additionally, some preventative screenings  will be provided free of charge, including breast and prostate cancer screenings.

9. Preventive and wellness services and chronic disease management—including counseling, screenings, and vaccines to keep people healthy and care for managing a chronic disease. Chronic disease treatment coverage is mandated as well as preventative care (e.g. immunizations, cancer screenings).

10. Pediatric services—including oral/dental and vision care for kids (but adult dental and vision coverage aren’t essential health benefits). Infants and children under the age of 19 are covered for medical conditions, treatments, and preventative treatments. Included is coverage of dental and vision care.

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