If you have Health Insurance, you're probably familiar with what your plan won't cover. The list of expenses denied when you file a claim can feel endless, so it's easy to wonder what is actually covered.
The U.S. Department of Health and Human Services published a list of ten "essential health benefits" under the Affordable Care Act (ACA) that define minimum coverage requirements for individual and small-employer plans and many Medicaid plans.
Those categories set a baseline for what most new plans must include, which helps consumers compare options and understand plan limits before enrolling.
Mandatory categories of coverage
- Outpatient medical care.
- Emergency care.
- Hospitalization.
- Maternity and newborn care.
- Mental health and substance use disorder services.
- Prescription drugs.
- Rehabilitation services and devices.
- Lab tests.
- Preventive and wellness services, and chronic disease management.
- Pediatric services, including dental and vision care.
Industry representatives noted that the minimum essential health benefits standard may require some individuals and small businesses to purchase coverage that is more comprehensive than they had chosen previously.
If you are planning to buy coverage under the ACA, review Understanding the Affordable Coverage Act and Health Insurance for background on how these standards affect plan options.
HHS also provides enrollment checklists and guidance for consumers about questions to ask when comparing plans and how to budget for coverage. For practical tips on comparing plan value and expected costs, see Understanding Health Insurance Costs and Coverage.
If you'd like personalized help selecting a plan that matches your needs, you can ask an agent to review your options.
Frequently Asked Questions
What are essential health benefits?
Essential health benefits are ten categories of services that must be covered by many health plans to ensure a baseline of coverage for consumers.
Do all health plans have to cover these benefits?
Many individual and small-group plans and new Medicaid benchmark plans are required to cover essential health benefits, though some plan types may be exempt.
Are prescription drugs included in essential benefits?
Yes, prescription drug coverage is one of the mandated categories and plans must include a range of medications within their formularies.
Does pediatric dental and vision count as essential benefits?
Pediatric services, including dental and vision, are included as part of the essential health benefits package.