What Are the 10 Essential Health Benefits?

Let’s take a quiz: How many of the 10 Essential Health Benefits can you name? First, a little background: Under the Affordable Care Act (ACA) of 2010, these 10 benefits must be covered by individual and group health plans in small-group markets (fewer than 50 employees). However, self-insured health plans are not subject to these ACA requirements.  

Prior to enactment of this law in 2014, individual health plans could choose not to provide maternity care or prescription drug coverage, for example. According to healthcare.gov, millions of people did not have coverage for several categories that are now included by the Essential Health Benefits: 

• 62% did not have coverage for maternity services.
• 34% did not have coverage for substance abuse services.
• 18% did not have coverage for mental health services.
• 62% did not have coverage for prescription drugs.

Here are the 10 Commandments of health care, if you will. Thou shalt cover: 

1. Ambulatory patient services. This is outpatient care, such as a doctor’s visit or same-day surgery, that you receive without being admitted to the hospital.
   
2. Emergency services. Insurance companies cannot charge more for going to an out-of-network emergency room in the case of a true emergency, such as a suspected heart attack or a stroke. They also cannot require prior approval for emergency room visits.
    
3. Hospitalization. This includes inpatient hospital stays. It’s important to know the difference between being admitted to a hospital for an observation stay and an inpatient stay – the two most common statuses. If one person is admitted with a severe case of vertigo and is discharged six hours later, that’s likely considered an observation stay. Meanwhile, the patient in the room next door may be considered sick enough to be admitted as an inpatient. Even though the patient who is there for a brief time is treated the same way as an inpatient stay, the insurance carrier will bill them differently – the former for individual services and the later as one main benefit.  
   
4. Pregnancy/maternity/newborn care. Insurance must cover medical services for moms and their child, before, during and immediately after birth. Insurers must also cover birth control and breastfeeding services. 
   
5. Mental health and substance use disorder services. This includes behavioral health treatment, such as counseling or psychotherapy. 
   
6. Prescription drugs. While insurers don’t cover all drugs, they must offer a formulary (an approved list of medications) for which they’ll pay a portion of the costs. 

For more information: How Do I Read a Prescription Drug List? 

     7. Rehabilitative/habilitative services and devices. This benefit includes devices or services for people with chronic conditions, disabilities or injuries.

     8. Lab services. Tests that doctors might run to aid in a diagnosis. 

     9. Preventive/wellness services. Preventive care covers routine doctor’s visits, such as annual exams and vaccinations from an in-network provider. Preventive health services include annual screenings like a pap test, mammogram, colonoscopy or vaccinations. This also covers chronic disease management. 

    10. Pediatric services. Children’s benefits must include vision and dental care until age 19. Some plans will extend this ancillary care until age 26, which is usually when adult children are no longer allowed to remain on their parents’ medical plan.  

Read more about young adult health care coverage here. 

Be aware that there is no guarantee that your health insurance policy will cover every service within the aforementioned categories. For example, your plan may cover one type of blood pressure medication and not another. Basically, policies have to cover something from each of the 10 categories, but exactly what is covered is not standardized. 

Benefits vary by state 

Each state has a “benchmark plan,” which sets the standards for the minimum level of coverage that all plans must offer. This means that while all of the 10 federally mandated benefit categories are covered in every state, the extent of coverage varies. Some states may require individual health plans to pay for weight-loss surgery, while others may not. Some may cover infertility treatments, while some may not. 

In the weeds: Insurance carriers in the individual and small group markets in each state use this benchmark plan as a guide for creating their own coverage. States can actually change their benchmark plan by selecting another state’s plan, replacing one or more categories of benefits from another state’s plan, or creating a new benchmark, as long as it meets the federal standards.