Essential benefits are care that health plans, except plans offered by large employers, must cover.
The goal for this set of benefits is to make sure you have access to basic health care. Essential benefits include:
- Addiction treatment
- Care for children (including vision and dental care)
- Care for newborn babies
- Maternity care
- Hospital care
- Doctor visits
- Emergency care
- Lab tests
- Mental health care
- Occupational therapy
- Physical therapy
- Certain prescription medicines
- Preventive care, like cancer screenings and vaccines
- Speech-language therapy
- Treatment for long-term diseases, like diabetes and asthma
The law also says that health plans must cover care for essential benefits no matter how much the covered costs add up to. There are limits on how much a health plan can make you pay for these services through your copays or deductibles.
Even though all plans must cover this list of benefits, there can still be some differences between states and health plans.
- States can replace an essential benefit with one of similar value. So read the list of essential benefits for each health plan you consider.
- Note that some health plans have more choices for each type of care. For instance, some plans may include weight loss surgery under hospital care and others may not. Under maternity care, some plans may cover in vitro fertilization and some won't.
- Be aware that while prescription drugs are an essential benefit, health plans may require you to pay higher copayments for certain drugs. So look at the formulary when you are deciding on a plan.