Health Insurance

What Are ACA Essential Health Benefits?

The 10 essential health benefits required by the ACA are essential to any insurance plan, but not always covered by carriers outside of the marketplace. Mothers, mental health sufferers, the disabled, and those on prescription drugs can benefit from a marketplace ACA plan.

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The Affordable Care Act has a minimum of 10 essential benefits that must be included in all marketplace plans. Even though they are only required for individual or small group plans, even larger groups and self-insured plans typically include these same benefits.

The 10 essential health benefits required by the ACA include: 

  • Emergency services
  • Ambulatory Patient Services
  • Hospitalization
  • Prescription drugs
  • Mental health and behavioral health services
  • Preventive and wellness services and chronic disease management
  • Rehabilitative and habilitative services and devices
  • Lab services
  • Pediatric services to include vision and dental
  • Maternity and newborn care

Emergency Services 

The ACA benefits include emergency services which is extremely helpful in cases where you may not be able to get to a hospital or urgent care facility that is within your network. Under the Affordable Care Act rules, the insurance carrier cannot charge you extra if you go out of network and receive emergency services. This is especially helpful when you may be traveling for work or pleasure.

Additionally, if you often need prior authorization for some other benefits, you won’t need it for emergency services under the ACA. 

Ambulatory Patient Services 

Ambulatory patient services mean that you can receive outpatient care without being admitted to a hospital, from doctor’s visits to same-day surgery.

The term ambulatory care refers to any health care you receive outside of a hospital. Diagnostic tests, treatments, and rehabilitation visits fall under this category.

Things like x-rays, blood tests, chemotherapy, colonoscopy, endoscopy, biopsy, mammogram, and many other imaging services and diagnostics tests are included under the ambulatory patient services essential health benefit. 

Hospitalization 

Overnight stays in a hospital, including for surgeries, is an essential health benefit of the ACA. Some plans can limit the time you can stay in the hospital, so be sure to understand what your plan covers. 

If you have a hospital stay planned for the future, you can check with your insurer to see what your out-of-pocket cost may be and if they limit the number of days you can stay. It is always a good idea to double-check your out-of-pocket costs since health care can be a major financial burden.

Prescription Drugs 

The government has categorized approved drugs into categories, and insurers must cover at least one drug from each category. Some drugs aren’t covered by insurers, but they must offer a formulary–and approved lists of medications–for which they’ll pay a portion. 

The easiest way to see what prescription drugs are covered and how much your insurer will pay is to check the website. Typically, there is a section where you can search for the name of the drug and they will tell you what your out-of-pocket cost will be. 

Mental Health Services 

An amazing required benefit of the ACA is mental health services. Counseling, therapy, psychotherapy, and other behavioral health services are a benefit that is required for all marketplace plans under the ACA. 

Mental health and substance abuse patients will be relieved to know that their plans must cover these mental health services and it is treated similar to the medical and surgical coverage that they are used to having. 

Preventative and Wellness Services 

Vaccinations and annual exams are part of preventive and wellness care, another essential health benefit required by the ACA. A pap test, for instance, is free if you get it from a provider in your network. But not all services at a checkup are covered, so you should check your benefits first. A key thing to remember here is in-network. This is not the same as emergency services which can be covered out-of-network. 

It is important that your wellness and preventative care are done with an in-network doctor so you can utilize this essential health benefit to its fullest.

Rehabilitative and Habilitative Services 

As part of the rehab and habilitative benefit, people with chronic conditions, disabilities, or injuries can access devices and services aimed at improving their skills or abilities.

While many plans outside of the marketplace now only cover services to help people regain skills, people with developmental and intellectual disorders will benefit from habilitative services to learn, keep, or improve functional skills.

Laboratory Services 

Lab tests that your doctor may order, such as blood or urine, are a covered benefit as well. Routine lab services are covered, and this is a great benefit because it means you and your doctor can stay on top of your health and offer more preventative care.

Typically, the tests included under the Affordable Care Act essential health benefit includes X-rays, MRIs, CT Scans, blood tests, urines tests, pregnancy tests, biopsies and other tissue samples, swab tests like strep, and even testosterone tests. 

Pediatric Care 

Pediatric care is one of the essential health benefits required by the Affordable Care Act. Children are covered for all of the 9 benefits we mention here, as well as vision and dental coverage. It is essential to note that vision and dental are only offered for children and are not included as an essential benefit for the adults on the plan. 

Maternity and Newborn Care 

Getting pregnant and having a baby can be so exciting, but the financial implications can be devastating. The ACA has made maternity and newborn care an essential health benefit. All women can rest assured that their maternity and newborn care will be covered under all marketplace plans.

You and your child must be covered for medical services before and after birth, including all delivery costs. Also, birth control and breastfeeding services, such as lactation consultants, must also be covered by insurers according to the Affordable Care Act. 

It is important to remember that these benefits will be subject to your deductible, and the limits may vary based on your plan. It is essential that you read your policy thoroughly to understand all of the inclusions and exclusions. However, each plan will have some coverage available under all of the 10 essential health benefits listed above.