To protect consumers, all plans on the Health Insurance Marketplace must cover the 10 essential health benefits set by the Affordable Care Act (ACA), no matter which metal tier (health plan category) you choose. The Marketplace is an online resource that provides access and enrollment to medical insurance, and was created as part of the ACA in 2010 to provide health insurance access to those who are not provided health insurance through an employer or other public program.
There are currently over 14,500,000 people who have enrolled through the Health Insurance Marketplace in 2022. However, the Marketplace is not the only way to purchase ACA-compliant health insurance coverage, as all employer-sponsored health insurance plans must also offer the ACA’s essential health benefits.
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What Are Essential Health Benefits?
All ACA-compliant plans must cover the following 10 essential health benefits:
- Ambulatory patient services
- Emergency services
- Laboratory services
- Mental health and substance use disorder services
- Pregnancy, maternity, and newborn care
- Prescription medications
- Preventive and wellness services and chronic disease management
- Pediatric services
- Rehabilitative and habilitative services
These are designed to provide affordable health care through a list of minimum-standard benefits. To enroll in health insurance through the ACA, you can sign up through the national Marketplace or your state’s version if one is offered, with the only difference being that a State-based Marketplace (SBM) is set up and run specifically through the state as opposed to through the federal government. All SBMs must still cover the same 10 essential health benefits.
Ambulatory Patient Services
Ambulatory patient services provide you with coverage for any outpatient care you may need. Outpatient care is defined as care where you are not admitted to a hospital. Outpatient care could take place, for example, if you visit your primary physician at their office and they schedule an annual blood test for you as part of your recurring check-up.
Emergency services provide you with coverage for any life-threatening medical attention you may need. Note that if you get emergency medical attention at an out-of-network hospital, your insurance company cannot charge you more for that visit. If you experience shortness of breath and pain in your chest and must go to an emergency room, your health insurance is obligated to provide you the same level of coverage even if you’re visiting family in another state.
Hospitalization provides you with coverage for any inpatient care you receive. If you require and receive surgery and end up recovering at a hospital for a few days, this part of your health insurance coverage is obligated to kick in. Hospitalization services also cover services you receive while in the hospital that are required as part of your medical treatment, such as laboratory services, rehabilitation, and more.
Laboratory services provide you with coverage for any testing required at a lab, such as blood work. It is common for physicians to request laboratory work as part of an investigation into your ailments and to ensure accuracy in your healthcare diagnoses.
Mental Health and Substance Use Disorder Services
Mental health and substance use disorder services provide you with coverage for things like mental and behavioral health inpatient services and treatment. These essential health benefits provide you coverage if you require counseling or psychotherapy after a traumatic death in your family, for example.
Pregnancy, Maternity, and Newborn Care
Pregnancy, maternity, and newborn care provides you with coverage before, during, and after birth. This essential health benefit includes pre-birth screenings, giving birth at the hospital, and post-birth doctor visits to ensure a healthy and safe pregnancy and delivery.
The prescription medications benefit provides you with drug coverage when you pick up prescribed medication at a pharmacy. However, this coverage may not take effect for new or experimental drugs.
Preventive and Wellness Services; Chronic Disease Management
Preventive and wellness services and chronic disease management benefits provide you with coverage for a wide range of medical services aimed at maintaining your overall wellness. Shots and screenings are often included in this essential health benefit coverage. Preventive and wellness services, however, do not often include coverage for chiropractic care, acupuncture, or other similar services.
Pediatric services provide your family with coverage for your children’s medical wellness. Pediatric services take care of regular wellness checks, shots, and a majority of routine lab tests. Children’s vision and oral care are also included in this coverage, such as if your kids need an eye exam to get fitted for their first set of glasses.
Rehabilitative and Habilitative Services
Rehabilitative and habilitative services provide you with coverage for services and devices aimed at helping you recover and live a normal life following an injury, disability, or chronic condition. For example, if you break your leg and need physical therapy to help you regain baseline mobility, your health insurance would cover that under this benefit.
How to Enroll In a Marketplace Plan
To enroll in a marketplace plan, visit your state’s marketplace or the national Health Insurance Marketplace. You can apply for your enrollment online or over the phone. Before enrolling, however, it’s important to consider a number of factors for your plan.
For example, you may want to consider the amount of monthly premium you can afford, which is the monthly cost of health insurance. Additionally, you may want to consider the amount of insurance deductible you can afford. Your deductible is the amount of money you pay into any covered medical services before your insurance kicks in to help pay for the bill. The lower your deductible, the sooner your insurance will begin paying for your healthcare, but plans with lower deductibles tend to have higher premiums.
Other costs to think about include the plan’s copay, which is a flat fee required to access any covered service, such as a doctor’s visit, and coinsurance costs, which is the percentage of a medical bill you’re responsible for paying. For example, a 50% coinsurance means you would pay 50% of the bill and your insurer would cover the remaining 50%.
If you miss enrolling in a health plan during the Open Enrollment Period (OEP), you may still qualify for a special enrollment period if you have a Qualifying Life Event. These events are typically major milestones and include losing health coverage due to job loss, getting married, moving, having a baby, and more.