The 10 Essential Health Benefits All Plans Are Required to Cover

The 10 Essential Health Benefits All Plans Are Required to Cover

Did you know that the Affordable Care Act (AKA: the ACA / Obamacare) requires all health plans within the Marketplace to cover certain health care services, known as “essential health benefits” (EHBs)?

Did you also know that before the ACA was enacted in 2014, less than 2% of the health plans in the individual market provided all 10 EHBs?! This requirement applies to health insurance plans both on and off the Marketplace, and prevents insurers from putting an annual or lifetime limit on the amount of cost they are obligated to cover for these services.

What are the EHBs?

The 10 EHBs aren’t actually specific services, they’re more like categories of services. Following are these services:

  1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  2. Emergency services
  3. Hospitalization(like surgery and overnight stays)
  4. Pregnancy, maternity, and newborn care ( before, during, and after birth)
  5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care (note: adult dental and vision coverage aren’t considered essential health benefits)

The specific services that an insurer covers within each category may differ slightly from state to state. Each state sets what is called a benchmark plan, which is the standard for what services all health insurance plans within that state must cover. So, while plans in every state cover the 10 EHBs, some states require insurers to include additional services, such as:

  • Dental coverage
  • Vision coverage
  • Medical management programs (for specific needs like weight management, back pain, and diabetes)

When comparing plans, state, federal, and private exchanges will show you the exact services that each plan covers, so be sure to check before you apply!

Other benefits health plans must cover

In addition to the 10 EHBs, plans must also include these other benefits:

Birth control:
All plans on the Marketplace must cover contraceptive methods and counseling for all women. Plans can’t charge you a copay or coinsurance for contraception, as long as you get it from an in-network provider. However, plans don’t need to cover drugs that induce abortions or services that affect male reproductive capacity, like a vasectomy.

Breastfeeding:
Most plans are required to include breastfeeding support and counseling. They also must cover the cost of breastfeeding equipment, such as a breast pump. These services may be provided before or after birth, or both.

Pre-existing conditions:
No health insurance plan can deny you coverage or charge you more money because of a pre-existing condition, which is a health problem you had before the beginning of your insurance coverage (asthma, diabetes, cancer, etc.).

Explore your options with W3ll

The 10 essential health benefits were designed to make sure the ACA plan of you select offers these services. While they may not fulfill all your needs, they’re a base to guarantee that you and your dependents are able to receive medical care.

Get started with W3ll to find the ACA plan that’s right for you. Answer a few questions about yourself and see your estimated savings and relevant insurance options instantly!