Essential Health Benefits Covered under the Affordable Care Act - dummies

Essential Health Benefits Covered under the Affordable Care Act

By Lisa Yagoda, Nicole Duritz, Joan Friedman

Copyright © 2014 AARP. All rights reserved.

Under the Affordable Care Act (ACA), all new health plans sold to individuals and small groups, whether through the Health Insurance Marketplace or not, must provide certain types of coverage that are detailed here.

To be clear, all nongrandfathered individual and small group market plans — employer-provided insurance plans offered by companies with 50 or fewer full-time equivalent employees — must offer this coverage as of 2014. (A nongrandfathered plan is not exempt from any of the ACA’s provisions. For more on grandfathered plans.)

All grandfathered large group, small group, and individual plans are currently exempt from this ACA provision. But because grandfathered plans can make only very limited changes to the benefits and premiums they had in place in 2010 or lose their grandfathered status, it’s anticipated that there will be increasingly fewer grandfathered plans.

If you shop for a plan on the Marketplace, or if you work for a small business that offers coverage through the SHOP Marketplace, here is some helpful information about what your insurance coverage must offer. (New individual and small group plans purchased via insurance agents and brokers must offer the same.)

Of course, your plan may offer more than these essential benefits, so don’t consider this information a substitute for your specific plan’s details.

Preventive and wellness care

Many people have important preventive and wellness benefits because of the ACA — with no deductibles and copayments.

The ACA provides for an annual well-woman visit for adult women under age 65 so that they and their doctors can determine what preventive services may be needed.

Pediatric care

Under the ACA, many health plans — including Medicaid and all insurance plans sold through the Marketplace — must cover certain preventive services for children at no cost to you (even if you haven’t yet met your plan’s deductible). Again, check your plan’s SBC for your specific coverage.

Prescription drugs

Before the passage of the ACA, many insurance plans offered prescription drug coverage only as an option at extra cost to you. But because of the ACA, all nongrandfathered individual and small-group plans, including all of those offered on the Marketplace, must provide prescription coverage.

The ACA specifically states that insurers must cover at least one drug in every category and class listed in the U.S. Pharmacopeia, which is an official publication of approved medications in the United States. This means that you may not get insurance coverage for a brand-name drug if your coverage instead applies to its generic equivalent.

Your insurer can give you a list (called a formulary) of the drugs your plan covers. When in doubt, speak with your doctor and/or pharmacist before you have a prescription ordered so you can take full advantage of this benefit.

Lab services

The ACA spells out which preventive screening tests must be covered by nongrandfathered individual and small-group plans, including all those sold on the Marketplace. You aren’t required to pay any out-of-pocket costs for these essential screenings.

However, when you have symptoms of disease, or if you’re seeking information about potential risks for disease, your doctor may order diagnostic tests that aren’t included in the list of fully covered screenings per the ACA.

Emergency services

Even before the ACA, most health insurance plans provided some form of coverage for visits to a hospital emergency room. So what’s different under the ACA?

As with the other provisions outlined here, this one applies to individual and small-group plans that aren’t grandfathered, including all those sold on the Marketplace. Check your plan’s SBC to find out what you can expect to pay for emergency care.

Ambulatory patient services

Don’t let the term confuse you: Ambulatory doesn’t involve an ambulance. This phrase refers to outpatient care — the kind you get whenever you walk into a doctor’s office or an urgent care facility, get treated for some kind of ailment, and walk back out. The ACA doesn’t have a tremendous impact on outpatient services because almost all health insurance plans already provided this type of coverage before its passage.

To pay the least out-of-pocket expenses for outpatient care, you generally need to visit a doctor who’s in your plan’s network. Be sure to check your plan details (starting with its SBC) to find out how to locate an in-network provider.


As with outpatient care, most insurance policies offered coverage for the costs of hospitalization even before the ACA. The ACA does stipulate that insurers must provide minimum essential coverage, however, which means that certain types of hospitalization policies aren’t sufficient.

For example, a plan that limits coverage to a set dollar amount each day (an indemnity plan) isn’t considered sufficient coverage by itself, per the ACA. You may want to purchase an indemnity plan to supplement your existing insurance, but that type of plan alone doesn’t provide the minimum essential coverage the law requires.

Maternity and newborn care

Before the ACA, many people got a nasty surprise when they discovered that their insurance policies excluded prenatal and maternity care. (As many as two-thirds of plans did so.) Under the ACA, prenatal care is classified as a preventive service that must be provided at no extra cost as part of nongrandfathered individual and small-group plans.

Mental health care

Before the ACA was signed into law, many health insurance plans didn’t cover mental or behavioral health services at all. Now, such services are considered to be essential health benefits that any nongrandfathered individual or small-group plan (including all plans sold on the Marketplace) must offer.

Such services aren’t required to be covered at 100 percent, so you may pay out-of-pocket expenses, such as copayments for office visits, just as with the medical care you receive.

Rehabilitative and habilitative services

To understand what insurers must cover, here are these terms defined:

  • Rehabilitative: These services help a patient who has been sick, hurt, or disabled to retain or regain skills or functions that are required for everyday life. Such services help relieve pain and support the ability to speak and walk, for example; they include coverage for canes, walkers, wheelchairs, and other devices that improve mobility.

  • Habilitative: These services are therapies that aim to help someone overcome a long-term disability. For example, someone who has Parkinson’s disease or multiple sclerosis may use habilitative services to try to retain the skills and functions he currently has and possibly try to regain some he has lost. A child with developmental delays that affect her skill development may also use habilitative services.

Dental and vision care for children

In addition to pediatric care, children under age 19 now have greater access to basic dental and vision services. All nongrandfathered individual and small-group plans must provide these services either within the plan itself or via an add-on plan.