The Affordable Care Act (ACA) – also known as Obamacare – introduced some standards to health insurance coverage. Before these reforms, health benefits offered by plans varied drastically across different health insurance coverage types. For instance, some plans would have prescription drug coverage, while others would not.
Today, health insurance plans approved by the ACA have a set of 10 essential health services that they must cover. The idea is to provide patients with more comprehensive health benefits without putting too much financial burden on them.
Keep in mind that short-term insurance plans and other types of plans that you buy directly from a private insurer outside of your Open Enrollment Period or Special Enrollment period may not have these 10 essential benefits.
Also keep in mind that “covered” does not necessarily mean “free.” Insurers can still have you cost-share for these services. This may mean paying toward your deductible or paying a copay or coinsurance.
Read on to learn more about the 10 essential health benefits that every qualifying health insurance plan in the U.S. should cover.
1. Prescription Drugs
The ACA mandates new qualified health plans to provide coverage for prescription drugs. Insurers are required to cover at least one brand of drug for every prescription drug that has been categorized and classified.
However, the guidelines do not say which brand of drug should be covered for each category, nor does it specify the cost. Most states give a benchmark plan for the list of medicines (also known as a formulary) covered by individual plans. When looking for an insurance plan, it is essential to look at their formulary to understand what drugs the plan will help you pay for.
While coverage for prescription drugs is mandatory, many health plans have different payment plans to ensure access and affordability to the drugs. Depending on the type of drugs, different insurance plans may have varying copay or co-insurance terms that may see their policyholders paying more for a specific medication than they would with another insurer.
Typically, drug lists are usually divided into four tiers from the cheapest to the most expensive. Tier 1 drugs are mostly generic and cost the least, while Tier 4 drugs are specialty drugs that usually are the most expensive. It is important to note that higher tier drugs are likely to cost you more in co-pay, co-insurance or prescription deductibles.
Some plans may require you to get preauthorization (also known as “prior approval”) for specific medications unless it is an emergency. Additionally, some plans will only cover medicines from specific in-network pharmacies.
2. Pediatric Services
The ACA requires that all health plans provide pediatric care services (including preventative health services) for all children 18 years of age or younger. Additionally, children are required to have additional benefits. While adult health insurance plans are not required to include oral and vision care, children’s health insurance plans must include both of these.
3. Ambulatory (Outpatient) Services
Your insurance plan should cover outpatient care services you receive without being admitted to a hospital. While you may receive an ambulatory service in a hospital setting, it is not considered a hospital admission, as you leave the same day you enter. These include services such as a visit to your doctor’s office, surgery, visits to an urgent care clinic and more.
4. Laboratory Services
All health plans are supposed to cover laboratory testing services that help diagnose, gauge effectiveness and provide preventive screens. This means that your health plan should cover routine tests that may be requested by a medical professional. These tests are essential to ensure safe and effective treatments.
Typical lab services that are covered by your care coverage benefits include the following:
- Blood and Fluid Tests
- X-rays, CT scans, MRIs and other Diagnostic Imaging
- Pathology such as throat swabs
- Pregnancy Tests
However, your insurance is not required to cover elective tests such as at-home drug tests and genetic tests. Remember, while your insurance plan may cover most of these services, it doesn’t mean that they’ll be cost-free. In some cases, you may be required to make payments in the form of copayment or coinsurance.
5. Emergency Services
If you have an emergency that needs you to get to the emergency room, you should get care from the closest hospital. Your insurance company should not penalize or charge you more in copayments or coinsurance even if you sought those services from an out-of-network hospital. You are also not required to seek approval from your insurer to seek emergency room services.
Whether you will need to pay anything or not after the services will depend on your plan and the hospital’s rules. Some hospitals, physicians, or ambulance companies may still bill you the balance remaining after your insurance company’s payment.
This includes all inpatient care services that a patient receives when hospitalized. An overnight stay at a hospital makes the service “inpatient” rather than “outpatient.” The ACA requires all health care plans to offer coverage for hospitalization services, including treatments, inpatient lab services, surgical care and pharmacy services. Some insurance policies, however, may limit coverage for an extended stay.
7. Maternity And Newborn Care
Your plan should cover a portion of all maternity, delivery and newborn care.
8. Mental Health And Substance Use Disorder Services
This includes all inpatient and outpatient behavioral health treatment, including psychotherapy, counseling services and substance abuse treatment.
9. Rehabilitative And Habilitative Services
These are services that help you recover or develop if you have a disability, had an accident or have a chronic condition. They apply to both mental and physical skills.
- Rehabilitative services are meant to help you gain lost abilities after a stroke or accident. These may include physical and occupational therapies.
- Habilitative Services are augmentative services to help gain new or late-acquired skills such as occupational or speech therapies for kids.
10. Preventive Services, Wellness Care And Chronic Disease Management
Insurance companies are supposed to pay the full cost for all approved preventative care services, so the patient doesn’t have to co-share. These are services that help you to detect or prevent a health condition at an early stage. This includes services such as:
- Colorectal cancer screening.
- Diet counseling.
- Type 2 diabetes screenings.
- Immunization vaccines.