The Affordable Care Act established essential health benefit categories for many individual and small-group health plans. The specific services, limits, and details are defined through applicable federal and state rules and plan documents.
The ten broad categories
Essential health benefits include:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Does every plan cover every service in the same way?
No. The broad categories do not mean every treatment has identical coverage. Plans can have medical-necessity rules, networks, formularies, cost-sharing, and other limits that comply with applicable law.
Preventive services
Many Marketplace plans must cover specified preventive services without cost-sharing when the legal requirements are met and care is received in the appropriate setting. Check the plan details for the services you need.
How to check your coverage
Review the Summary of Benefits and Coverage, Evidence of Coverage, and insurer directory. Ask the insurer how a specific service is covered before scheduling it.
Important: Coverage varies by plan and state. Consult HealthCare.gov and the official plan documents for current details.
