The Affordable Care Act put in place 10 essential health benefits that health insurance policies must cover. These policies include those offered through a state Marketplace, sold on the individual market, or offered through small employers (those with 50 or fewer employees). Plans that existed prior to March 2010 that have not substantially changed do not have to include the essential health benefits. Short-term health plans – those in effect for less than 12 months – also do not have to offer these benefits. Finally, large employers do not have to offer the essential health benefits, although the majority do so. The essential health benefits are broad service categories such as emergency room visits, prescription drugs, and lab tests.
Within these categories, each state has the option to provide greater details on the services that are covered. So depending on where you live, there may be differences in the essential health benefits. Here’s a list to help you sort it out. Check with your insurance company if you have specific questions. That way you'll know ahead of time what you'll have to pay for on your own.
Essential Health Benefits:
- Ambulatory Care -- also known as out-patient care, such as a visit to your primary care doctor
- Emergency Services
- Hospital Care
- Maternity and Newborn Care
- Mental Health and Substance Use Services
- Prescription Drugs
- Rehabilitative and Habilitative Services -- for example, treatment that can help you recover from a stroke or treatment that can help a child with autism spectrum disorder learn to speak
- Laboratory Services
- Preventive and Wellness Services
- Pediatric Services
Cosmetic surgery: Most insurance plans did not cover cosmetic surgery before the Affordable Care Act, and that hasn’t changed. But some plans do cover plastic surgery if it’s needed for a medical reason. For instance, if you have a baby born with a birth defect, your insurance might cover it.
Weight-loss surgery: This depends on the state. Nearly half of the states cover weight loss surgery. Check with your state's Marketplace to find out.
Substance abuse counseling: This is considered an essential health benefit that insurers must cover.
Dental: Your health insurance does not have to offer dental care for adults. However, insurers must offer dental coverage for children. If you buy insurance through the Marketplace, this may be part of your regular health plan. Or you may have to buy a stand-alone dental plan if you want coverage for your children. It's up to the states to decide whether to require parents to buy these plans for their children.
Vision: You'll find the same limits on vision care as on dental care. Insurance companies don’t have to offer vision coverage for adults, but they do for children. You might have to buy a stand-alone vision plan to cover your children in some states.
Breastfeeding: Any plan bought through a Marketplace, on the individual market, or through your small employer must offer breastfeeding support, counseling, and equipment. Your plan must cover the cost of a breast pump, but your insurance company can decide whether to buy you a new one or rent one for you, and specify the kind of pump you can get.
Home health care: All states include home health care in their definition of essential health benefits. Home care may be subject to limits on the number of visits.
Chiropractic care: Most states cover this type of care, but check with yours to make sure. In some states, your insurance must pay for a chiropractic doctor who provides medical services that are essential health benefits.
Acupuncture: Only a handful of states cover acupuncture. Check with your Marketplace.
Psychotherapy: Mental health benefits are considered an essential benefit and are covered. The law also requires that mental health benefits be equal to a plan’s coverage of medical or surgical care.
Long-term care: You will need to pay for long-term care if you become disabled or need to move to a nursing home. It's not an essential health benefit under the Affordable Care Act and is not covered by Medicare or most private health plans.
Abortion: Abortion is not one of the essential health benefits. States have the right to ban abortion coverage in health plans sold on the state Marketplace. Check with your individual plan to see whether it is covered.