Essential Health Benefits

Essential health benefits under the Patient Protection and Affordable Care Act will include the following general categories:

• These essential health benefits include at least the following items and services:
• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Hospitalization
• Maternity and newborn care (care before and after your baby is born)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services including oral and vision care

According to the Affordable Care Act, plans of all sizes that cover benefits designated as Essential Health Benefits, including self-funded plans, must cover these benefits with no annual limits or lifetime maximums.

Summary of Benefits and Coverage

Under the Affordable Care Act, health insurers and self-funded employers must provide a uniform Summary of Benefits and Coverage (SBC) to people who apply for and enroll in health policies.

Insurance companies and group health coverage must provide you with:

• A short, plain-language Summary of Benefits and Coverage (SBC)
• A Uniform Glossary of terms used in health coverage and medical care

This information allows you to make “apples-to-apples” comparisons when you’re looking at different coverage.
 

All individual and group health policies must use the same standard form to help you compare policies. The SBC also includes details, called coverage examples, which allow you to see what the policy would cover in two common medical situations: diabetes care and childbirth.
 

The SBC is available for every policy in the Health Insurance Marketplace. You’ll find a link to it on each policy page when you enroll through the website.
 

You can also ask for a copy from your insurance company or group health administrator at any time. All health policies must provide the SBC to you at important points in the enrollment process, like when you apply for or renew your policy. You can also ask for a copy of the Uniform Glossary to help you understand words used in health coverage and medical care.

Preventive Health Services for Adults

Most health plans must cover a set of preventive services like shots and screening tests at no cost to you. This includes Marketplace private insurance plans.
 
Preventive care helps you stay healthy. A doctor isn’t someone to see only when you’re sick. Doctors also provide services that help keep you healthy.
 
Free preventive services

All Marketplace plans and many other plans must cover the following list of preventive services without charging you a co-payment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
2. Alcohol Misuse screening and counseling
3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
4. Blood Pressure screening for all adults
5. Cholesterol screening for adults of certain ages or at higher risk
6. Colorectal Cancer screening for adults over 50
7. Depression screening for adults
8. Diabetes (Type 2) screening for adults with high blood pressure
9. Diet counseling for adults at higher risk for chronic disease
10. HIV screening for everyone ages 15 to 65, and other ages at increased risk
11. Immunization vaccines for adults (visit www.healthcare.gov for a full list)
12. Obesity screening and counseling for all adults
13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
14. Syphilis screening for all adults at higher risk
15. Tobacco Use screening for all adults and cessation interventions for tobacco users