Under the Affordable Care Act (ACA or Obamacare), every health insurance plan must cover a specific set of health services called “essential health benefits”, or EHBs. These benefits ensure that everyone in the individual and group market has equal access to the same benefits and services, regardless of pre-existing conditions.
Essential health benefits have no annual or lifetime limits. This means there’s never a cap on coverage for any of these services. It also means that you can still get care for a medical issue covered by these services, even if you had been dealing with the medical issue before enrolling in insurance.
Obamacare’s 10 Essential Health Benefits
Every traditional health insurance plan must include these 10 categories of medical care. The essential health benefits are:
- Chronic disease management, preventive care, and wellness services
- Outpatient care (or “ambulatory patient services”)
- Emergency services
- Hospitalization (inpatient care)
- Laboratory services
- Prescription drugs
- Mental health and substance use disorder services, including behavioral health treatment
- Rehabilitative or habilitative services and devices
- Maternity and newborn care
- Pediatric services (including oral and vision care for children)
1. Chronic Disease Management, Preventive Care, and Wellness Services
According to the ACA, your insurance plan must cover most preventive care for free, even if you haven’t met your deductible for the year. Preventive care is a way to either prevent or identify specific health conditions or diseases. That is to say, preventive care aims at the prevention – and not treatment – of health issues. Preventive care generally includes screenings and immunizations, based on an individual’s age and risk factors.
- Screenings: Screenings for cholesterol, cancer, depression or diseases are all considered preventive care.
- Checkups: Annual checkups and physicals are included. Specialized checkups for certain populations – such as hearing tests for children or gestational diabetes screenings for pregnant women – are also covered.
- Immunizations: Many popular immunizations, including the flu shot, are considered to be preventive care. Vaccines for chickenpox, tetanus, and other conditions are also included in your health plan.
Your plan must also cover ongoing care for any chronic diseases you may have. Since your insurer cannot pick and choose which conditions to treat, your plan will maintain care for all chronic diseases. Chronic disease management includes ongoing care for issues such as heart problems, asthma and multiple sclerosis, among others.
2. Outpatient Care (Ambulatory Patient Services)
When you plan to see a family physician, you’re getting outpatient care, known as “ambulatory patient services.” These services go against your deductible and are sometimes repriced at a lower negotiated rate.
- Care Received Without Being Admitted to a Hospital: This benefit applies whether you’re seeking routine outpatient care, or something as in-depth as same-day surgery.
- Care Provided by a Doctor or Specialist Must be Covered: Care from any doctor or specialist will be covered according to the rules of your plan. According to ACA guidelines, your plan’s essential health benefits “must be equal in scope to the benefits” covered by major medical plans, meaning that your plan can’t refuse to cover a type of doctor if most other plans include this coverage. Your health plan will also cover doctors who treat a specific body part or condition.
3. Emergency Services
Your plan is required to cover you if you go to the hospital for any reason. Whether you have an injury like a broken bone or a sudden illness such as a stroke, all emergency services are included among the 10 essential health benefits, so they are covered.
- Emergency Treatment Is Covered: Medical treatment of your urgent and acute health issues will be a part of your plan.
- No Penalty for Going Out-of-Network or for Not Having Prior Authorization: Since you should be able to see a doctor as quickly as possible in an emergency, your insurer cannot require prior authorization before you seek emergency treatment. You can’t be charged a higher copayment for going out-of-network. However, you may wind up getting billed for higher-cost out-of-network care once your insurer has paid its share.
- Ambulance Costs Are Covered: Emergency services coverage includes ambulance transportation to get you to care safely.
4. Hospitalization (Inpatient Care)
Once you’ve been admitted to a hospital, your coverage will continue; your inpatient care is considered part of your essential health benefits.
- Anything Associated With Your Hospitalization Is Covered: This means that any medical professionals you see will be covered. The services that they provide in the hospital will also be covered, including medical imaging and testing. Drugs that are given to you in an inpatient hospital setting will also be covered, as will the cost of staying at the hospital.
- You’ll Still Be Responsible for a Portion of the Costs: Even though insurance will cover your hospital stay, you’ll still be responsible for a portion of the costs per your specific health insurance policy – whether that’s satisfying your deductible and/or coinsurance. Be careful – it’s easy to accidentally accept expensive take-home equipment or a private room that didn’t seem optional at the time.
- To Prevent Surprise Bills, Specify That You Want to Stay In-Network: You’ll need to specify that you only want in-network treatment to prevent surprise medical bills. Your insurance company may have different rules for in-network and out-of-network doctors, both of whom will work at the hospital. To guard against getting overcharged by your hospital, make sure to connect with your insurance company or the hospital’s billing department once you or a family member are able to do so.
5. Laboratory Services
Laboratory services are another important component of care that plans can’t omit. Your outpatient care would be less effective if these services weren’t covered (considering doctors need information from these tests to better diagnose your condition or illness).
- Medically Necessary Lab Services Are Covered: Medically necessary blood tests, x-rays, and outpatient medical imaging will be covered by your health plan.
- Some Preventive Screenings Are Provided: Screenings for things like breast cancer and prostate exams are included.
6. Prescription Drugs
Whether it’s antibiotics or medication to treat a chronic health condition, prescription drug coverage must be provided as an essential health benefit.
- Doctors Must Meet Minimum Conditions When Prescribing Medication: At the very least, your health insurer must cover one drug in every category and class of the United States Pharmacopeia, a non-profit guide that determines drug standards. Although the specific brand you want may be unavailable, your plan will have a pharmaceutical treatment available for all common conditions.
- Your Plan Must Have Some Procedure in Place for Specialty Drugs: Your plan must have a way for you to request and access clinically appropriate drugs that are not ordinarily covered by the plan. This may likely include prior authorization for medication, requiring your doctor to gain approval from a third party, known as a “pharmacy benefit manager.”
7. Mental Health and Substance Use Disorder Services (Including Behavioral Health Treatment)
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- Common Mental Health and Substance Abuse Treatments Are Covered: The full spectrum of common mental health treatment will be covered. If you seek substance abuse treatment, you’ll have a similarly wide range of options. Just be aware, your insurance may not cover long-term residential drug rehabilitation that stretches beyond several weeks. Under the ACA, the level of mental health and substance use treatment included in your plan must be similar to what your plan offers for comparable medical services.
- Diagnostic and Counseling Services Are Covered: Your plan will cover both diagnostic and counseling services for mental health and substance abuse issues after your deductible is met
8. Rehabilitative or Habilitative Services and Devices
Rehabilitative benefits like physical therapy or speech development were some of the least commonly offered services prior to the ACA. Now, your insurance must cover these post-injury treatments along with your initial health issue. The devices associated with your treatment, including hearing aids or walkers, can also be covered by your plan. The difference between habilitative and rehabilitative care is whether or not you had the skill before your injury.
- Rehabilitative Care: Rehabilitative care encompasses treatment for someone who needs to keep or regain a skill for daily living. Follow-up treatment to fully recover from acute, debilitating injuries is covered. Treatment of long-term issues without an immediate cause, like back pain, is also included as part of your essential health benefits.
- Habilitative Care: Habilitative care involves learning an important skill for the first time, such as speech for children who have never talked. You can get habilitative care to improve skills for daily living.
9. Maternity and Newborn Care
Maternity care is one of your essential health benefits. Your plan will cover care during pregnancy and the delivery of your baby, as well as some postpartum services after the birth of your child.
- What’s Covered: Labor and associated hospital costs during the delivery will be covered. Prenatal care such as pregnancy evaluations and ultrasounds are included in your coverage. Pregnancy-related screenings for diabetes, drugs, and diseases are part of your plan. Support continues for family planning services (like breastfeeding or sterilization) after your child is born.
- Men Can’t Remove This from Their Plan: Men cannot “un-bundle” this coverage from their plan. Although men won’t need maternity coverage for themselves, every health plan shares the cost of maternity coverage so that insurance remains as affordable as possible for new families.
10. Pediatric Services (Including Oral and Vision Care)
The ACA also ensures that every plan provides healthcare to children and infants.
- Plans Should Include Care for Infants and Children: Under the ACA, healthcare for children and infants is required as an essential health benefit. This would include doctor checkups and important vaccines and immunizations..
- Basic Vision and Dental Care: The ACA is very clear about vision and dental care. Your plan must provide basic vision and dental care to children on your plan until their 19th birthday. The associated dental care will include exams, cleanings, restorative services like fillings, and medically necessary orthodontic work. Childrens’ vision care will include an annual eye exam that offers glasses or contact lenses.
Some plans include oral and vision care for those 19 and above. Other carriers sell stand-alone dental and vision plans for adults for an additional premium. However, these benefits are only mandated by law for those 18 and under.
Using Essential Health Benefits to Help You Compare Health Insurance Plans
These essential health benefits provide a good guideline that you can use to consider and compare plans. For the most part, you can be confident that each of the plans you look at will take care of your basic health needs. When it comes down to comparing your health insurance options, it’ll likely come down to: provider network size; the amount you’ll spend on copayments and your deductible; and additional benefits that certain plans may offer.
Since medicine is constantly changing, your health insurance plan will review its coverage guidelines each year to make sure they are up-to-date. When defining your plan’s benefits, your insurer is required to “take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.”
What Do Essential Health Benefits Not Include?
While the essential health benefits under Obamacare enable everyone to receive comprehensive coverage, there are a few common medical procedures that are unlikely to be covered by most health insurers.
- Medical Management Programs: Programs that address ongoing health-related issues such as weight loss are not always covered, although many plans still see the benefit in providing them.
- Scientifically Valid but Medically Unnecessary Procedures: Procedures and services such as fertility-related treatments or LASIK surgery are generally not covered by health insurance companies.
- Cosmetic Surgery: Cosmetic surgery will not be covered by traditional insurance, outside of circumstances where it is medically necessary.
Are There Any Exceptions to Essential Health Benefits?
Faith-based plans and short-term health insurance are not required to offer essential health benefits. These plans are alternatives to health insurance, not exact substitutes. Additionally, large companies that self-insure their employers, and religious companies can make some adjustments to their coverage. Otherwise, there are very few exceptions.
Whether or not you receive health insurance through the individual market or your employer, the benefits will be the same. Individual health insurance benefits are supposed to mirror “benefits provided under a typical employer plan.” If your plan has a metal level – like silver, bronze, or platinum – then you’re covered with full essential health benefits. Medicare and Medicaid work off of their own set of rules, although their benefits are similar.