Since 2014, the Affordable Care Act (ACA) has mandated that insurance plans cover 10 specific services. This mandatory list of services applies to many individual health plans or plans offered through the small-group marketplace (employers with up to 50 employees). Because these general services have been deemed “essential,” they are known as the 10 Essential Health Benefits (EHB).
What Are the 10 Essential Health Benefits?
Here is a list of the 10 essential health benefits and what they mean.
- Prescription Drugs
The federal government has categorized approved prescription drugs. One from each category must be covered.
- Pediatric Services
This includes dental care, vision care, well-child visits, vaccinations, and immunizations. Dental and vision care must be offered to children through the age of 19 (pediatric oral health services can include two routine dental exams per year; ocular care can include one annual eye exam).
- Preventive and Wellness Services and Chronic Disease Management
This includes services such as diet counseling, colorectal cancer screening, Type 2 diabetes screenings, and immunization vaccines.
- Emergency Services
This is a trip to the emergency room where you truly need care as soon as possible. It means that you won’t be penalized if the hospital is out of network.
Treatment you receive in the hospital as part of inpatient care. Plans may limit coverage for extended stay.
- Mental Health and Addiction Services
This includes services to treat behavioral health, provide counseling, or provide psychotherapy.
- Pregnancy, Maternity, and Newborn Care
These are services that care for you and your baby before, during, and shortly after giving birth.
- Ambulatory Patient Services
This is outpatient care you receive without being admitted to the hospital.
- Laboratory Services
This includes testing to diagnose, to gauge effectiveness, and some preventive screenings.
- Rehabilitative and Habilitative Services and Devices
These services help you recover if you are injured, have a disability, or have a chronic condition. Services may include physical therapy, occupational therapy, or speech therapy.
Are My Needs Outside of the 10 Essential Health Benefits Covered?
The 10 essential health benefits do not guarantee that your health insurance policy will cover any service within the 10 categories. Even within our list you may notice that only one prescription from every categorized medication must be covered.
For example, you could be prescribed a generic blood pressure medicine called “bumetanide,” but your health insurance only covers “spironolactone,” despite the diuretic differences. This means that if you want your coverage to apply to the former medication, you would need your doctor to switch your prescription. However, if you find one formula serves your health better than what is covered under your health insurance policy, the entire cost of the prescription would be out-of-pocket.
The 10 essential health benefits were designed to make sure individual and small-group health insurance plans offer you these services. Although they may not fulfill all your needs, they are a sturdy base to make certain that insured adults and dependents are given the opportunity to receive much needed medical care.
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