A Basic Explanation

If you’re buying your own health insurance (meaning you’re not getting your coverage through an employer, or as part of any other group plan), you’re guaranteed coverage for 10 “essential” services. No matter which plan you buy on the marketplace, you’ll get these 10 benefits.

Expert Advice About Essential Health Benefits

You’ll want to know about the 10 essential health benefits (EHB) that new plans must include so you can take full advantage of your insurance coverage. If you need healthcare, these benefits will have a significant impact on your life.

1. Maternity and Newborn Care

You’ll no longer have to worry about maternity and childbirth exclusions on your policy. Under the Affordable Care Act (ACA), insurers must cover maternity, childbirth, and your newborn baby’s care.

2. Pediatric Services

If you have children, you know that even routine healthcare can bust the budget. You’ll no longer be charged for many preventive services — including most childhood vaccinations. Your child’s eye care will also be covered, as will some dental care (if your plan includes dental coverage or you purchase separate pediatric dental insurance).

3. Preventive Services for Adults

You know those tests doctors say you should have every year but you skip because you’re not covered? Now, even if you haven’t reached your annual deductible, you won’t have a copayment for an annual wellness visit or for a host of preventive services, including cholesterol screening, colonoscopies, mammograms, pap smears, and prostate exams, depending on your age and gender.

4. Emergency Services

When an emergency strikes, you can concentrate on your health and well-being instead of wasting precious time trying to figure out if your insurance policy will cover your emergency room visit. You won’t need preauthorization to go to the ER, and you can’t be charged higher copays or coinsurance if you visit an out-of-network hospital’s emergency room when things go wrong.

5. Hospitalization

If you need to stay in the hospital for treatment for an illness or for surgery, your insurance has to help cover your costs at in-network facilities once you meet your deductible. And once you reach your out-of-pocket limit, your insurance has to pay 100 percent of your in-network essential health benefit expenses.

6. Ambulatory Patient Services

That’s just a fancy way of saying your outpatient care when you don’t need to go to the hospital.

7. Prescription Medications

New health plans must cover at least one drug in every category and class listed in the U.S. Pharmacopeia, the official publication of medications in this country. This means that while not all specific drugs are covered, at least one of each type or “class” of medication must be covered. When you pay for prescription medications, it counts toward your total out-of-pocket expenses.

8. Mental and Behavioral Health

Mental and behavioral health services, including counseling and treatment for substance-abuse disorders, get a boost under the new healthcare law. Behavioral assessments for children and preventive services — such as depression screenings for adults — are covered. The total cost to you and the number of sessions covered vary by state.

9. Rehabilitative and Habilitative Services and Devices

If you’ve been injured, are ill, or have a chronic condition, many of your rehabilitative services will be covered. This includes physical, occupational, and speech-language therapies. Your plan may also include coverage for medical equipment like canes, wheelchairs, and walkers. However, individual policies may differ on exactly which therapies are covered and for how long. Your plan may or may not include coverage for long-term disabilities and diseases. If you have a chronic condition, investigate the specifics before choosing your plan.

10. Laboratory Services

Lab tests like routine blood screenings are covered if they are for recommended preventive care. If your doctor orders a test for diagnostic purposes, you’ll probably have some kind of payment, depending how your plan is structured.

Limits and Exceptions

These healthcare essentials offer a lot of great benefits, but there are some restrictions you’ll want to keep in mind:

  • There may be limits on how often you can use preventive services.
  • You may still have to meet your deductible and/or pay a copay when services are ordered for diagnostic rather than preventive purposes.
  • These benefits may apply only if you use in-network providers.
  • These essential benefits are required for new individual and small group plans. They may not be included as part of self-insured or large employer-provided group plans or grandfathered plans (plans created or purchased before March 23, 2010).

The bottom line? Shop wisely: Ask questions and compare plans.