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Understanding the Health Care Law’s 10 Essential Benefits
Last January, the Patient Protection and Affordable Care Act (ACA) greatly expanded the healthcare benefits available to Americans. The law set certain standards that all insurers must meet as well as mandated that all ACA compliant health insurance plans cover 10 essential benefits.
1. Ambulatory Patient Services
All health insurance plans must provide outpatient care. Networks and available doctors will vary by plan, but the ACA states that the network’s size must be “sufficient” to meet demand.
2. Prescription Drugs
While many previous insurance plans required add-on prescription drug coverage, the ACA mandated that all individual and small-group plans must cover at least one drug in every category and class of approved medications. While the cost for these drugs will vary (some plans require you to meet a separate drug deductible before you can benefit from price reductions), they will count towards your out-of-pocket maximums.
3. Emergency Care
In many cases, previous health insurance plans already covered a portion of emergency room visits. Under the ACA, however, they can no longer you to obtain preauthorization before seeking treatment, nor can they charge you more if you must go to an out-of-network emergency facility.
4. Mental Health Services
While many old health insurance plans did not cover mental or behavioral health services, the ACA mandates that all new plans must include these benefits for reasonable copays. However, there may be a limit set on the number of covered therapy visits you can make each year.
5. Hospitalization
Under the ACA, all compliant health insurance plans must cover at least a portion of hospitalization costs—and all costs if you’ve reached your out-of-pocket limit. Hospitalization coverage also includes care received in a skilled nursing facility, though some plans may limit that coverage to no more than 45 days.
6. Rehabilitative Services
Compliant individual and small-group health insurance plans must cover rehabilitative services (such as speech therapy after a stroke or physical therapy after a knee replacement) as well as habilitative services (such as speech therapy for children) and associated devices. Plans must cover 30 visits each year for physical or occupational therapy as well as speech therapy and cardiac or pulmonary rehab.
7. Preventative and Wellness Services
ACA compliant plans must allow you a free wellness visit with your doctor each year as well as cover 50 additional preventative services at no extra cost. These include a number of cancer screenings, immunizations and other health screenings. You can find a complete list here.
8. Laboratory Services
All new individual and small-group insurance plans must cover testing used to diagnose injuries, illness and conditions and monitor the effectiveness of treatment. While the preventative screenings in the list mentioned above are free, you will usually be required to pay a fee for diagnostic tests.
9. Pediatric Care
In addition to well visits and recommended immunizations, plans must include additional coverage for children under the age of 19, such as twice-yearly dental cleanings, dental x-rays, fillings and medically necessary orthodontic treatment. They must also cover an eye exam and one pair of glasses or set of contacts each year.
10. Maternity and Newborn Care
Individual and small-group plans must provide prenatal care at no additional cost—something nearly unheard of in old insurance plans. They must also cover childbirth and newborn infant care, though some benefits are subject to deductibles, copays or coinsurance.
