10 Essential Health Benefits Under the ACA (2023)

ÖAffordable Care Act(ACA, also known as Obamacare) sets basic standards related to the total benefits that individual/family and small group health plans must cover. This article explains what these benefits are, how they are regulated, and how they vary from state to state.

Before the Court of Auditors came into force, the scope of health insurance varied greatly from state to state and from plan to plan. Consumer protection consisted of a patchwork of government regulations, strict in some states and minimal in others.

More comprehensive state requirements than the Court of Auditors still apply, but the Court of Auditors has set minimum standards in all federal states. Essential Health Benefits (EHB) are ten types of health benefits that need to be coveredno dollar limits on annual or lifetime benefits— On all major individual and small group health plans with an effective date of January 2014 or later. EHBs are covered whether or not the plan is soldthrough the exchangeÖout of the bag.

OwnmiOwnPlans still exist but had effective dates prior to 2014. Therefore, SFIVET requirements do not apply to earned and earned plans, except for retirement, which must be covered by earned but unearned plans.

Most EHB requirements also don't apply to large group plans (in most states, "large group" means 50 or more employees, although there are four states where the limit is 100+ employees).However, the benefits described in more detail below apply to large group plans (includingAuto Insurance Plans) as well as individual and small group plans.

See what EHBs are and how they work:

outpatient services

This includes visits to doctor's offices and clinics, as well as outpatient hospital care (“outpatient” refers to walking, so refers to outpatient services).People sometimes assume that ambulatory services refer to ambulances and emergency transport, but that's not the case.)

Treatment of chronic diseases, wellness care and preventive services

Provision is covered withoutsharing coststo the patient (i.e. the insurer pays the full cost), but only if the benefit concerned is ongoingthe list of covered pension benefits.

Unlike the rest of SFIVET, large groups and pension benefits must be coveredAuto Insurance Plansas well as individual and small group plans (all other EMSs only have to be covered by individual and small group plans).

There are four agencies whose recommendations are used to create the list of benefits covered. These agencies include the U.S. Preventive Services Task Force (USPTF), the Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration's (HRSA) Bright Futures Project, and the HRSA's Health Services Committee, Preventive Clinics for Women and the Institute of Medicine (IOM).

The list is primarily based on services rated "A" or "B" by the US Preventive Services Task Force (USPSTF).Breast cancer screening for women ages 40 to 49 has only a “C” rating from the USPSTF, but an exception was made to include it in the ACA's list of covered screening services.

In addition to the USPSTF guidelines, the CDC's Advisory Committee on Immunization Practices (ACIP) makes immunization recommendations and the Health Resources and Services Administration (HRSA) provides additional recommendations for preventive care for women, infants, and children.

It typically takes a year for new coverage recommendations to be added to benefits covered by health plans (and the delay can actually be up to two years, as it applies to the next renewal after a year).; if the plan is renewed near the one-year mark, benefits do not need to be added until the next renewal).

But the process wasmuch faster for the COVID-19 vaccine. Just 15 days after the FDA issued the first emergency use authorization in December 2020, health plans were required to fully cover the vaccine.

Contraception is insuredin the provision, i.e. without costs for the insured person. However, health insurance only has to cover at least one version of each of the FDA-approved types of female contraceptives, which means there are many specific contraceptives that still come with costs, with details varying from policy to policy and others. .

emergency services

While health insurance plans can limit most coverage to in-network providers, the same is not true for emergency services.

Your health insurer cannot impose a higher co-payment for emergency care at an off-network hospital and must allow you to go to the nearest emergency room even if it is not on your plan's network.

The obligation to cover emergency treatment by health insurance also extends to patient transport, including air ambulances.

And from 2022 the federal governmentlaw without surprisesprohibits the collection of credits in emergency situations, with the exception of ambulance costs. This protection applies to individual, small group, and large group plans, including self-insured plans.

hospitalization

This includes the full spectrum of hospital care, including medical and nursing treatment, inpatient laboratory and pharmacy services, and surgical care.

laboratory services

Laboratory work that falls within the scope of preventive care described above is taken on free of charge for the patient.

Other laboratory work required is covered by the plan's normal cost-sharing policies.

Maternity and Newborn Care

This includes all maternity, childbirth and newborn care, although prenatal check-ups are generally covered by preventive care benefits (described above) and can be covered at no cost to the mother-to-be. According to HRSA, prenatal care falls under the category of women's care. And while this is covered once a year in most cases, the agency notes that in some cases "multiple visits may be required to get all the recommended preventative services you need."

In addition to the tests themselves, there are some specific tests (gestational diabetes, hepatitis B and Rh incompatibility) that are considered for pregnant women as part of the no-cost prevention modality.

Mental health and substance abuse treatment

This includes inpatient and outpatient treatment for the treatment of mental illness and substance abuse.

Mental health parity requirementsThey predate the ACA, although the ACA expanded the parity law to apply to both individual marketplace plans and employer-sponsored coverage. Under the parity requirement, a health insurance plan cannot have more restrictive coverage limits for mental health care than for medical/surgical care.

Pediatric services including dental and eye care for children

Unlike the other EMSs, pediatric dentistry is not required to be included in the exchange's healthcare plans as long as a separate pediatric dentistry plan is also available at the exchange.

award allocations arenot necessarily presentto cover the cost of dental care when purchased as separate stand alone coverage on the Exchange. The subsidy amount available may or may not be based on the addition of the cost of a separate standalone dental plan. It depends on how premiums compare when adding the cost of a standalone dental plan to the cost of silver plans that don't cover children's dental benefits.

There is no obligation for health plans that cover adult dentistry or eye care.

prescription drugs

Individual and small group plans must cover prescription medications and theirsto formmust contain at least one drug in each United States Pharmacopeia (USP) category and class (or more if the statereference planecontains more).

The formularies are also being developed with input from the Pharmacy and Therapy (P&T) Committees, but may differ significantly from health plan to health plan.

According to the preventive guidelines outlined above, health insurance plans must cover at least one FDA-approved version of each type of female contraceptive for insured persons, free of charge.and recommended vaccinations.

For other medications, the plan's co-payment rules apply. And plans may requireStep by step therapy(requirement that the insured person start with the least expensive and least risky drugs to see if they work before trying more expensive and risky drugs) orprior approvalfor expensive drugs.

Most health insurance companies discontinue covered medicationsfour or five levels. Tier 1 drugs have the lowest cost price, and Tier 4 or 5 drugs (usually specialty drugs) have the highest cost price.

rehabilitation and qualification services

This includes therapies and devices that are necessary for rehabilitation and habilitation.

Rehabilitation services focus on regaining lost skills, such as occupational therapy or physical therapy after an accident or stroke.

Habilitation offers help to acquire skills in the first place, such as speech therapy or occupational therapy for a child who does not speak or walk as expected.

Generally, there are limits on the number of visits per year (although plans may not impose dollar limits on EMSs, visit limits are allowed). Some states have the limit for a combination of physical therapy, occupational therapy, and speech therapy, while others have separate limits for each type of therapy.

Within the SFIVET categories, states define what needs to be covered

Although the Court of Auditors identifies ten categories of services that individual and small group insurers must cover, the law leaves some leeway for states to define exactly what that coverage should be. Each state can choose onereference planefor it, and these plans differ from state to state.

Although ACA's essential health care benefits are included in every ACA-compliant individual or small group plan throughout the United States, details regarding minimum coverage requirements vary from state to state.

Summary

Under the Affordable Care Act, health plans in the individual/family and small group markets are required to provide coverage for ten basic benefit categories known as essential health care services (EHBs). Health insurers cannot set caps on how much they will pay for services that fall into these categories, but cost-sharing (deductible, co-payment, co-insurance) may apply to most services. The ACA defines the ten categories of coverage broadly, but each state defines (through a benchmark plan) the specific services that must be covered under each SFIVET category.

A word from Verywell

Whether you buy your own health insurance or are covered by a small employer, the ACA Essential Health Services rule helps ensure that your policy does not have significant coverage gaps. Before the ACA, it was fairly common, particularly in the individual/family market, to see plans that didn't cover things like maternity care, psychiatric care, or even prescription medication. But thanks to SFIVET rules, such plans are no longer sold in the major medical market, on the stock exchange or over the counter.

However, it is important to understand that plans that are not regulated by the ACA can still be sold to EMS without coverage. So things likeShort term health insurance,Ministry plans to share health care,fixed compensation plans, etc. they are not required to cover EMSs and generally continue to have gaps in their coverage.