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  • Writer's pictureJo Soria

Understanding the 10 Essential Health Services Your Marketplace Insurance Plan Covers

One of the provisions of 2010's Affordable Care Act (ACA) is the requirement that all health insurance plans offered in its public Health Insurance Marketplace cover, at minimum, a set of 10 essential health services and/or benefits (EHBs). Join the #TRN team as we review this helpful list!

Parents with little girl in field; 10 essential health services

The 10 Essential Health Services Breakdown

Here are the ten essential health services that each insurance policy must cover under the ACA. These benefits ensure that planholders and their families receive comprehensive care within a standardized framework. Keep in mind that while ACA Marketplace plans are subject to meeting this requirement, plans on the private insurance marketplace are not.


While some of the essentials on the list are a little more intuitive than others, reviewing each category can help you understand what's available.


1. Ambulatory Services

Ambulatory patient services, commonly known as outpatient care, involve medical services provided without requiring an overnight hospital stay. Such covered services include visits to primary care physicians, specialists, and outpatient clinics.


These services are crucial for preventive care, ongoing management of chronic conditions, and treatment of acute illnesses and injuries.


2. Emergency Services

Emergency services cover care for acute medical episodes that require immediate attention and care, such as heart attacks, strokes, or severe injuries. Under the ACA, health insurance plans cannot impose higher copayments or coinsurance for emergency room visits to out-of-network hospitals, ensuring that patients receive the care they need without financial barriers in critical situations.


3. Hospitalization

Hospitalization benefits cover the costs associated with being admitted to a hospital for treatment. This includes surgeries, overnight stays, and nursing care. Coverage for hospitalization is vital for severe health conditions that require extensive medical intervention and monitoring.


4. Maternity and Newborn Care

The ACA mandates that health insurance plans cover maternity and newborn care. This includes prenatal visits, labor and delivery, and postnatal care. Coverage also extends to necessary newborn services, such as screenings and vaccinations. Ensuring comprehensive care during pregnancy and childbirth is crucial for the health of both mother and baby.



5. Mental Health and Substance Use Disorder Services

Mental health and substance use disorder services encompass a range of treatments for conditions such as depression, anxiety, and addiction. In recognition of the integral role of mental well-being in overall health, the ACA Marketplace requires health plans to cover psychotherapy, counseling, inpatient care, and medications.


6. Prescription Drugs

Prescription drug coverage is a key component of the ACA's essential health benefits. This includes coverage for a wide range of medications necessary for treating various medical conditions. Health plans must include at least one drug in every category and class of the U.S. Pharmacopeia, ensuring access to essential medications for chronic and acute conditions.


7. Rehabilitative and Habilitative Services and Devices

Rehabilitative services help individuals recover skills and functions lost due to illness, injury, or disability. On the other hand, Habilitative services assist those with developmental disabilities in acquiring or improving skills necessary for daily living. This category includes physical therapy, occupational therapy, speech therapy, and devices such as wheelchairs and hearing aids.


8. Laboratory Services

Laboratory services cover diagnostic tests, such as blood work and pathology, necessary for diagnosing and managing health conditions. These services also include preventive screenings like cholesterol checks and diabetes tests. Timely access to lab services is essential for detecting health issues early and monitoring ongoing medical conditions.


9. Preventive and Wellness Services and Chronic Disease Management

Preventive and wellness services are designed to prevent illnesses and promote health. This includes vaccinations, screenings for conditions such as cancer and heart disease, and counseling for lifestyle changes like smoking cessation and weight management. Chronic disease management services provide ongoing care and support for individuals with long-term health conditions, ensuring they receive the necessary treatments and monitoring to maintain their health.


Kids pillow fighting on bed; 10 essential health services

10. Pediatric Services, Including Oral and Vision Care

The ACA ensures that children receive comprehensive health coverage, including pediatric services, oral care, and vision care. Pediatric services cover routine check-ups, immunizations, and developmental screenings.


Oral care includes dental check-ups, cleanings, and treatments, while vision care covers eye exams and corrective lenses. These services are crucial for the early detection and treatment of health issues and support the overall well-being and development of children.


When in Doubt, Check With an Expert (for Free)

Understanding the basics of your ACA healthcare plan can help you make informed decisions and ensure that you and your family are receiving the necessary care. For more detailed information, consider visiting reputable sources like healthcare.gov.


Better yet, consider consulting a licensed health insurance agent who can help you understand these ten essentials and help you shop for the best-packaged policy offerings for you and your family. They've got the know-how and the backstage pass to the healthcare industry; and best of all, you don't have to pay anything out of pocket to access their expertise.



 

Want to be part of the #TRN Community? We are looking for guest writers to contribute topics to our blog. Contact jo@trustedreferral.org to learn more.



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