Essential Health Benefits & Preventive Services


Under the Affordable Care Act, each Qualified Health Plan (QHP) is required to cover a set of ten essential health benefits (EHBs) in order to be sold on the health insurance marketplace. This provision applies only to the individual health insurance market, not employer-sponsored plans. Individual plans sold outside of the marketplace must also pay for EHBs in order to comply with the health law. This requirement makes it easier for policyholders to receive necessary care without worrying if it’s covered or not. While these categories are broad and leave room for insurers to interpret the details, health plans will likely be required to cover numerous services that fall into these groups. Prior to this law, several EHBs, notably maternity care and mental health benefits were difficult to get covered and often included waiting periods and supplemental coverage, if a health policy offered them to begin with.

Another covered category of services advocated by the ACA is prevention, which has been expanded to include additional services for women, children, and insured individuals of all ages at no cost. Obamacare makes it possible for the insured to receive any form of prevention at no extra charge under their plan. Insurers must cover preventive care at 100 percent, whether it’s an immunization for your child or a mammogram.

 

Essential Health Benefits

The following ten categories of services must be covered by all non-grandfathered individual health plans under Obamacare, beginning January 1, 2014:

  1. Emergency room visits
  2. Laboratory services
  3. Prescription drugs
  4. Doctor’s office visits
  5. Hospitalization
  6. Maternity and newborn care
  7. Pediatric services
  8. Prescriptions
  9. Mental health and substance abuse disorder care, including behavioral health (covers counseling and psychotherapy)
  10. Preventive and wellness services and chronic disease management

 

Preventive Care

Prevention is stressed by the ACA because using your resources to keep track of your health before you get sick can save you as a patient, insurers and medical providers large sums of money. Now that the government plays a role in healthcare, it’s in their best interest to keep Americans healthy, as well. TheĀ cost of healthcare increases each year not only due to overall inflation but also due to the amount of people receiving expensive services. In order to make preventive care more appealing and easily obtainable, the health law requires all plans to cover such services in full. This includes various vaccinations, screenings, and prevention counseling for high-risk individuals.

The plans that must cover preventive services include non-grandfathered private health plans, or those with effective dates beginning after the ACA was signed into law on March 23, 2010. If you have a non-grandfathered, or reformed plan, this provision applies to your policy. Covered in full means that private insurers cannot charge coinsurance, copayments, or deductibles to patients receiving such services. Most preventive care requirements took effect for reformed plans on September 23, 2010, and beginning August 1, 2012, the number of services increased to include various women’s health services. Some preventive care must be offered to all patients, while other types of care are available for specific groups only, such as women and children.

The Kaiser Family Foundation created the table below as a summary of cost sharing-free health benefits that must be included in health plans sold after March 2010. Click to view the full chart.

Preventive Care Under ACA