Essential Health Benefits
Essential Health Benefits or Minimum Essential Coverage is any health insurance that meets the Affordable Care Act requirement for coverage. Every health plan must help pay for 10 Essential Health Benefits, which include:
1. Ambulatory patient services. Also known as “outpatient care.” This is any health care you receive outside of staying at a hospital (examples: doctor’s office visits, clinic visits, emergency room visits).
2. Emergency services. Any unscheduled medical care that is performed immediately to treat a condition.
3. Hospitalization. The admission to the hospital for the treatment of a medical condition.
4. Pregnancy, maternity, and newborn care. This is the medical care that an expecting mother receives before, during, and after labor.
5. Mental health and substance use disorder services. Treatment for both substance use disorders and mental health problems. This may include rehabilitation, support groups, talk therapy, and medications.
6. Prescription drugs. The federal government has grouped approved prescription drugs. One from each group must be covered.
7. Rehabilitative and habilitative services and devices. Health care services that help with the skills necessary for daily living. These services may include occupational and physical therapy, speech-language pathology, and other services for people with disabilities in different settings.
8. Laboratory services. This includes testing to diagnose, to gauge effectiveness and some preventive screenings.
9. Preventive and wellness services and chronic disease management. Includes services such as diet counseling, colorectal cancer screening, Type 2 diabetes screenings, and immunization vaccines.
10. Pediatric services. This includes dental care, vision care, well-child visits, vaccinations, and immunizations. Dental and vision care must be offered to children through age 18.
- Job-based plans
- Health Insurance Marketplace plans
- Most individual plans bought outside the Marketplace
- Medicare
- Medicaid
- The Children's Health Insurance Program (CHIP)
- TRICARE
- COBRA
- Plans sold through the Small Business Health Insurance Program (SHOP) Marketplace
Note: Review the summary of benefits in your health plan to ensure that your plan includes coverage for your specific needs in addition to the 10 Essential Health Benefits. You may want to have non-essential benefits covered if they are important to you.
Non-essential benefits include:
1. Diabetes Self-Management Education and Support (DSMES). DSMES provides individually tailored services to help people manage their diabetes and related conditions through evidence-based practices.
2. Orthotics. A device (example: a brace) for muscles, joints, or skeletal parts which need support.
3. Hearing aids. A small device that fits in or on the ear, worn by an individual who needs sound amplified.Chiropractic
4. Manipulation. This treatment involves moving the joints within or beyond their normal range of motion to help ease pain.
5. Meals, travel, and lodging for transplant operation.
6. Acupuncture. The insertion of fine needles through the skin at specific points to ease pain.
7. Wigs. A covering of hair for all or most of the head, of either natural or synthetic hair, worn for aesthetic purposes.
List of health plans that do not count as qualifying health coverage:
- Coverage only for vision care or dental care
- Workers' compensation
- Coverage only for a specific disease or condition
- Plans that only offer discounts on medical services
- Short-term health plans
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