The Affordable Care Act (ACA), sometimes referred to informally as Obamacare, is a health care reform law passed in 2010. The Act has three fundamental purposes, but its primary one is to make health insurance options available and affordable to more people across the country. Under the ACA, you can buy individual or family health insurance plans from private insurers through the online exchange known as the Health Insurance Marketplace. All ACA-qualified health insurance plans MUST cover the 10 Essential Health Benefits (EHBs) covered in this article.
Before the government passed the ACA, less than 2 percent of health insurance plans across the country offered all of these ten benefits, which led to a vast majority of the American population paying hefty medical bills for health care services that they could not possibly afford. EHBs are generic service categories deemed as necessary for the population.
Before explaining each one, it is vital to understand that under every section, there might be some non-covered services for your particular scenario. Also, the ACA allows each state to set a state benchmark, meaning the specific services a plan must cover to qualify under Obamacare for that particular state.
The fact that a service is covered doesn’t necessarily mean that it’s going to be completely free, though. It just means insurers can’t deny it to you, and they must treat it like other eligible health care services. You may still have to pay cost-sharing payments like deductibles, coinsurance or copayments.
Feel free to check all these particulars during the Open Enrollment Period or during a Special Enrollment Period when you qualify to apply for health care. Lastly, bear in mind that these 10 EHBs only apply to ACA-approved health insurance plans, which you can get through the Health Insurance Marketplace. For example, other short-term health insurance plans you purchase directly through an insurer may not offer the ten essential benefits.
What Are the 10 Essential Health Benefits of the ACA?
- Ambulatory Services
Also known as outpatient care, ambulatory services are one of the most commonly used types of EHB, since any health care you receive from outside of a hospital counts as ambulatory. For example, an ambulatory service is when you visit your doctor’s office because of a cold or a sore throat or a pre-existing condition. Sometimes, your plan might cover the full costs of ambulatory services, although that’s not always the case.
- Prescription Drugs
The United States Pharmacopeia (USP) sets the industry’s standards for drugs and medicines approved for the American market under different classes and categories. For every section and subsection, you must be able to have at least one drug option covered. Several plans will still require you to spend some out-of-pocket money for these drugs. Your expenses should count towards your deductible, though.
- Pediatric Services
Before you get the age limits all mixed up, here is some clarification. The ACA covers dependents until reaching the age of 26. However, pediatric services are available only until the child reaches the age of 19.
Unlike adult plans, pediatric care is required to include dental and vision care. Benefits include two teeth cleanings per year, an annual eye examination, and a choice between glasses or contact lenses when required. Note that the ACA doesn’t require any health insurance plan to cover dental and vision for adults. This benefit requirement applies only towards children.
- Preventive and Wellness Care Services
The ACA requires insurance companies to completely cover preventive services, making them free for you. Preventive services are a defined set of health care services designed to prevent health problems from developing or worsening. There are specific preventive care services for women, men and children.
Examples of preventive care services include well-woman exams, domestic violence screenings, breastfeeding support, contraception, prostate exams and other general health screenings, patient counseling and check ups. Additionally, health insurers must cover treatments for pre-existing chronic diseases.
- Laboratory Services
These services are tests on your body, such as urine tests, blood tests or x-rays, that help diagnose or treat health conditions in patients. In most cases, your primary care physician will refer you to a specialist to run these diagnostic tests. When used to diagnose a particular illness, your health insurance plan must pay for them in full. Otherwise, copays and deductibles usually apply.
- Emergency Services
Under the ACA, no insurance company can deny you emergency care, charge you extra for these services if you get them out of your network or place them on hold until getting a pre-authorization. You may have to make cost-sharing payments.
This category includes surgery, overnight stays and other types of medical care in a hospital. Your health insurance plan must cover hospitalization services. However, understand that even if insurers are required to cover these services, they are not required to pay for them in full.
- Mental Health Coverage and Substance Use Disorder Services
Seeing a psychologist, seeking therapy, receiving treatment for substance abuse and other mental or behavioral health services are some of the covered services included under the ACA. Cost-sharing may apply.
- Habilitative and Rehabilitative Services and Devices
Habilitative services are forms of health care that help you with those skills deemed necessary for your daily routine: for example, occupational therapy, physical therapy, speech-language impairment therapy and other services designed to help you achieve or recover physical or mental skills.
Rehabilitative services include skill development treatment you need to get back to your daily routine after losing them due to getting sick, hurt or disabled. Habilitative services refer to skill development services for a condition unrelated to a particular event.
- Pregnancy, Maternity and Newborn Care
Any qualified health plan must cover pregnancy services, childbirth services and newborn services.
Additionally, giving birth classifies as a life-changing event, meaning you can apply for a special enrollment and get new insurance or switch to a different health insurance plan to cover your needs better. All plans must allow you to include your child in your health plan after being born.