Essential Benefits and Health Reform

New private insurance plans must cover a core group of benefits, called essential health benefits. These services are similar to those in a typical employer plan -- and in some cases better.

10 Benefits New Plans Should Cover

1. Addiction treatment and mental health care

2. Care for children. This includes:

3. Doctor visits

4. Emergency care

5. Hospital care

6. Lab tests

7. Medicines your doctor prescribes

8. Physical, occupational, and speech-language therapy. These services help you get back on your feet after a serious injury, surgery, an event like a stroke or long-term health problem. This care can also help you overcome a disability, like a speech problem. Coverage includes:

  • Therapist visits
  • Tools, called durable medical equipment, like braces or a wheelchair

9. Pregnancy and maternity/childbirth care

10. Preventive care and treatment for chronic illness. This includes:

Note: Although all health plans must cover these services, the benefits can vary from one state to another.

Will Your Plan Cover Essential Benefits?

You will get these benefits if:

  • You are buying individual or small group insurance, which is offered through a company that has fewer than 50 full-time employees.
  • You are going to receive Medicaid for the first time.

Your health plan may not cover the benefits if:

  • You have a "grandfathered" plan. This is a plan that was already in place before the Affordable Care Act was signed into law on March 23, 2010 and has made few changes since then.
  • Your plan is self-insured. Large employers commonly have self-insured health benefits. That means an employer contracts with an insurance company to administer the plan, but the company pays medical claims out of its own funds.

 

Limits on Essential Benefits

Which treatments for back pain are covered under the essential benefits? How many times can you see a physical therapist? There will still be some limits on what your insurance company will pay. Here are rough guides to those limits:

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Your state sets a benchmark plan. For now, each state decides which services, tests, and tools all of its private plans must cover. To do this, each state chooses a typical employer plan to use as a model, called the benchmark plan.

If the benchmark plan covers in vitro fertilization or autism spectrum disorder treatment, for instance, your plan will, too. If the benchmark plan doesn't cover these, your plan may still cover them, but it doesn't have to.

Check out your state's benchmark plan at the federal government's CCIIO web site.

Your health plan can limit visits. Your insurer may only pay for a certain number of visits on some types of care, like physical therapy, for example. Check the fine print in your plan's summary of benefits.

Your health plan cannot cap the cost of care. Each year and over your lifetime, your plan cannot put a dollar limit on covered essential health benefits. So if you have a serious or chronic illness, once you reach your plan’s out-of pocket maximum, your insurer will pay the full cost of care provided by in-network providers.

WebMD Medical Reference Reviewed by Smitha Bhandari, MD on May 31, 2016

Sources

SOURCES:

Community Catalyst & Georgetown University Health Policy Institute: "Restricted Annual Lifetime Limits," "Preventive Coverage."

HeathCare.gov.

Kaiser Permanente: "Understanding Exchanges." Qualified health plans -- the metal tiers."

Robert Wood Johnson Foundation: "Health Policy Brief: Essential Health Benefits."

U.S. Department of Health and Human Services: "Essential Benefits: HHS Information Bulletin."

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