All plans offered in the Marketplace cover these 10 essential health benefits:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Plans must also include the following benefits:
- Dental coverage
- Medical management programs (for specific needs like weight management, back pain, and diabetes)
When comparing plans, you’ll see exactly what each plan offers.
Are the benefits the same in each state?Open
Generally, yes. But some states require insurers to cover additional services and procedures. Even within the same state, there can be small differences.
When you compare plans in the Marketplace, you’ll see the specific benefits each plan offers.
What if I need a specific treatment that’s not on this list?Open
Plans may cover other services. When you compare plans, you’ll see more detailed information about what’s covered. If you want to find out if a particular service is covered, call the plan.
Do all types of Marketplace plans cover essential health benefits?Open
Yes. Any plan shown in the Marketplace includes these essential health benefits. This is true for all plan categories (all “metal levels,” including Catastrophic plans) and all plan types (like HMO and PPO).
Do I have to pay deductibles and copayments for essential health benefits?Open
Generally, yes. All Marketplace plans have deductibles, copayments, and other out-of-pocket costs that apply to most covered services. Some preventive services are free, and some plans cover other services without out-of-pocket costs.
Do I get these benefits if my company is self-insured?Open
It depends. Large employers who “self-insure” — meaning they pay employees’ health care costs directly — don’t have to provide essential health benefits. But many do. Check with your employer to find out if it’s self-insured and what services are covered.
Are abortion services covered by Marketplace plans?Open
Sometimes, and plans may have different restrictions. Some offer no coverage or coverage with restrictions. In some cases abortion services cannot be paid for with federal dollars (these are known as “non-Hyde” abortion services).
Contact each plan to learn about its abortion coverage.
Do I get these benefits if I have a grandfathered plan?Open
It depends. Many grandfathered plans cover essential health benefits, but they’re not required to. To be sure, check with your employer or health plan.
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