Health insurance is a complicated—and often touchy subject. A complex web of regulations, definitions, costs, and options, if you haven’t gone through the process, the seemingly endless set of choices can seem overwhelming.
Paired with the removal of the ‘shared responsibility payment,’ or the penalty for not having compliant individual coverage under the tax reform law, and understanding what you’re required to have is even more complicated. That said, especially in the wake of a pandemic and an economic downturn that has resulted in many individuals venturing out to buy insurance on their own for the first time, understanding your options has never been more important.
The Ten Essential Benefits Required by the ACA
During the creation and passage of the Affordable Care Act, policymakers determined ten “essential health benefits,” designed to make sure individual and small group health insurance plans offered a quorum of services to be considered federally recognized.
Though not all plans (i.e. short-term insurance) offer this, if a plan is to be Healthcare.gov certified and delivered through the marketplace, a plan must cover the following:
Ambulatory patient services
Any time that you receive care without entering a hospital, you receive ‘ambulatory patient services’. The most common type of service that a person uses, this covers the common procedures provided by family medicine or a general practitioner.
Additionally, specialists are included under this category, although with varying costs pertaining to copays.
Preventive and wellness services and chronic disease management
If you visit a doctor for your annual checkup and walk out with no copay, this is likely part of the coverage known as preventive care. The goal of covering this is to avoid an illness to take a turn for the worse and ultimately cost both you and your insurer more. Preventive care covers the following:
- Screenings:Screenings for cholesterol, cancer, depression, or other diseases are all considered preventive care.
- Checkups:Annual checkups and physicals are included. Specialized checkups for certain populations are included.
- Immunizations:Many popular immunizations, the flu shot, vaccines for chicken pox, tetanus, and other conditions will be included in your health plan.
There are three sets of free preventive services—for children, women, and the general adult population.
Emergency services
Emergency services means that if you go to a hospital for any reason, your insurer needs to cover you and will do so without penalizing you for going out of network.
In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can’t charge you more for getting emergency room services at an out-of-network hospital.
Hospitalization (like surgery and overnight stays)
Following admission to a hospital, insurance covers inpatient services, and anything associated with the hospitalization is covered. Knowing this, you still will be responsible for a portion of costs depending on your policy, and whether you are in- or out-of-network.
Pregnancy, maternity, and newborn care (both before and after birth)
Maternity care and childbirth — services provided before and after your child is born — are essential health benefits. This means all qualified health plans inside and outside the Marketplace must cover them. An essential health benefit, plans are required to cover care during pregnancy, the delivery of your baby, and postpartum services.
Additionally, becoming pregnant is a qualifying life event that allows for a Special Enrollment Period.
Mental health and substance use disorder services, including behavioral health treatment
All Marketplace plans cover mental health and substance abuse services as essential health benefits. This means that all plans must cover:
- Behavioral health treatment, such as psychotherapy and counseling
- Mental and behavioral health inpatient services
- Substance use disorder (commonly known as substance abuse) treatment
Prescription drugs
One of the more complicated essential health benefits, a health insurer must cover one drug in every category and class of the United States Pharmacopeia, a nonprofit organization that sets the standards on which drugs and medicines are approved for use.
In short, one medication may be covered for the treatment of a specific category of disease, and in this, you may need additional authorization or may need a change of prescription to be covered.
Rehabilitative and habilitative services and devices
Another essential health benefit, rehabilitative and habilitative services and devices refer to services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.
One of the least commonly offered services prior to the passage of the ACA, this may include rehabilitative (keeping or regaining a skill) or habilitative (gaining skills required for daily living).
Laboratory services
Often connected both to ambulatory services or preventive medicine, laboratory services are another essential benefit that aids the prevention or diagnosis of a disease or condition. This may include medically necessary blood tests, x-rays, and outpatient medical imaging, as well as preventive screenings for breast or prostate cancer.
Pediatric services, including oral and vision care
Children under the age of 19 can get a variety of health care services, including a variety of dental and vision services. Under this, children are afforded two annual teeth cleanings and orthodontic care, eye exams for children, and glasses and contacts. Adults are not included in this coverage.
Essential Means Different Things to Different Residents
One of the hardest parts about offering access to health insurance for more than 300 million Americans spread across 50 states is that each locality is different. Residents of each state have different needs, different cost tolerances, and different challenges, making a one-size-fits-all program impossible.
This means that Essential Health Benefits mean a lot of different things to a lot of different people. On one hand, it allows a state to tailor the required services to its population; on the other, it creates a vast difference in cost structures, risk pools, and the like for every state. While a state like Illinois may require insurers to cover bariatric surgery or hearing aids, head across the border to Indiana and neither is required.
Even a decade after the Affordable Care Act was passed, finding health insurance is still one of those things that is a mystery for many Americans. If you’re looking for help understanding your options, Insurance Broker Hub can help.
Our free service gives you access to an independent network of national brokers who have the experience and expertise to design a plan around your needs and budget. Ready to get started? Simply request a no obligation health insurance quote here.
