Purchasing private health insurance coverage through the Health Insurance Marketplace is an option for those who do not otherwise have traditional health insurance coverage through an employer, their spouse or parents, or Medicare/Medicaid. Marketplace health insurance plans are governed by the Affordable Care Act and are required to include certain coverage and benefits for all patients enrolled in a plan.
Essential Benefits
Here are the 10 categories of essential health benefits that are covered by all plans:
Ambulatory patient services
This includes medical care received without needing to be admitted to a hospital, often called outpatient services.
Emergency medical services
If the condition is deemed an emergency, care at the closest emergency facility is covered, even if out of network.
Hospitalization
Surgeries, overnight hospital stays, and inpatient care are covered.
Pregnancy and newborn care
This covers maternity care for the mother and baby before, during, and after birth. Plans may also include additional coverage for birth control and breastfeeding services.
Mental health and substance abuse disorder services
This includes treatments such as behavioral health, counseling, and psychotherapy.
Prescription drugs
Each insurance plan will have different prescription medication coverages and exceptions, as well as in-network pharmacies, but all must provide coverage.
Rehabilitative and habilitative services and devices
These include any devices that help patients with injuries, disabilities, or chronic conditions to gain or recover mental and physical skills.
Laboratory services and tests
These are tests ordered by a doctor (commonly blood, urine, or saliva) to aid in the diagnosis of a condition.
Preventative and wellness services, including chronic disease management
Pediatric services, including dental and vision care
However, plans do not need to include dental or vision coverage for adults.
Preventative Care
All plans cover preventative healthcare services at no cost to the patient when delivered by an in-network doctor or provider. Preventative services include annual physical exams, screenings for certain diseases, patient counseling on common health topics (such as smoking cessation, healthy eating, losing weight, treating depression, reducing alcohol use, etc.), well-baby and well-child visits, and routine vaccinations. Preventative services also routinely include management of chronic diseases like diabetes and heart disease.
Guaranteed Acceptance
In addition, Marketplace health insurance plans are required to offer guaranteed acceptance to patients even if they have a pre-existing medical condition. No insurance plan offered on the Marketplace can reject, increase rates for, or refuse to pay for essential health benefits for patients with a condition that existed prior to coverage starting. Once enrolled, patients do not need to worry about being denied coverage or rates increasing based on health status.
Additional Benefits
While these essential benefits are minimum requirements under the Affordable Healthcare Act, many Marketplace plans also offer additional benefits like dental coverage, vision coverage, and medical management programs. Few plans cover alternative or experimental treatments.
We’re Here to Help You
Because there are varying options of coverage available with health insurance plans on the Marketplace, it is helpful for individuals to work with a certified insurance agent to find the right plan for their unique needs. Our committed agents at LEB Insurance Group are available to assist and guide you toward the right insurance solutions. Contact us today.
