Let’s begin with a little background. To ensure higher quality coverage in health plans, the Affordable Care Act (ACA) sought to discover a sturdy base for health insurance requirements. The ACA, as of January 2014, has created a list of services that health insurance plans must provide coverage for. This mandatory set of services applies to individual plans or plans offered through the small-group markets place (employers with up to 50 employees). Because these general services have been deemed ‘essential’, they are known as the 10 essential health benefits.
The Lavish List
Let’s get straight to the 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 18 (2 routine dental exams; 1 yearly eye exam with corrective lenses).
- Preventive and Wellness Services and Chronic Disease Management
Includes services like: counseling; cancer, asthma, diabetes screenings; physicals; and vaccines.
- Emergency Services
Basically, this is a trip to the emergency room where you truly need care as soon as possible. This also 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. Many health insurance plans already provided this coverage prior to the ACA, because it’s the most common form of healthcare.
- 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. At least 30 physical therapy, occupational therapy, or chiropractic visits. At least 30 speech therapy, cardiac, or pulmonary rehab visits.
Insider Advice (10 essential health benefits, but not all needs)
The 10 essential health benefits do not guarantee that your health insurance policy will cover any service within the 10 categories. Even within our “Lavish List” you may notice that only 1 prescription from every categorized medication must be covered.
What does that mean? Well, let’s look at an example using prescription drug coverage. Say you are prescribed a generic blood pressure medicine called “bumentanide,” but your health insurance only covers “spirolactone”, despite the diuretic differences. This means that if you want your coverage to apply to this 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.
A Sturdy Base
The 10 essential health benefits were designed to make sure individual and small group health insurance plans offered you at least these services. Although they may not fulfill all of 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.