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What are the 10 Essential Health Benefits?

Helping you understand the standard coverage of your health insurance plan

Key Takeaways

  • Under Obamacare or the Affordable Care Act (ACA), health plans must cover the same 10 Essential Health Benefits.

  • OutpatientOutpatient refers to medical services that don't require an overnight hospital stay. care, emergency care, hospital stays, mental health coverage, prescription drugs, rehab services, lab services, free preventive carePreventive care is medical care that aims to prevent serious diseases and injuries. These include immunizations, physicals, screenings and more., maternity and newborn care, and pediatric care are all named essential health benefits.

Common Ground for All Health Insurance Plans

In many ways, health insurance has become relatively predictable. Under the Affordable Care Act (ACA)The Affordable Care Act is a healthcare reform bill from 2010 aimed at reducing the amount of uninsured Americans by making coverage more affordable. Also known as The Patient Protection and Affordable Care Act, the ACA requires insurance companies to cover preventive care and other essential health benefits. Also known as "Obamacare.", health insurance plans must cover the same essential health benefits. To many, this is a welcomed change that offers comprehensive coverage and saves you money in the long run.

Plans require coverage for the following ten essential health benefits: 

1. Outpatient Care

Outpatient Care refers to medical services that do not require an overnight stay. Outpatient Care is performed in qualified medical facilities like ambulatory surgery centers — usually not in hospitals. Critical outpatient services include Wellness and prevention, diagnosis, treatment, and rehabilitation. Typically, all services provided occur in one location, and you are not admitted.

2. Emergency Care

An unfortunate reality of life? 

Even the healthiest of people aren’t immune to emergencies. Without adequate coverage, the cost of emergency care can be a substantial financial burden.  With a major medical health insurance plan, you can have peace of mind that there is coverage for unforeseeable medical emergencies requiring immediate treatment. 

Under Obamacare or the ACA, there is no penalty for seeking emergency care at an out-of-network hospital — meaning you can seek care at the closest facility without fear of denied coverage.

3. Hospital Stays

Sometimes a specific condition or procedure requires admission to the hospital and overnight stays. Think of it this way: The average cost of a three-day hospital stay is around $30,000 [1] — so having adequate coverage helps protect you from hefty unexpected costs like these. Unexpected hospital stays do not jeopardize the value of your benefits moving forward. This is because health plans in the Marketplace can no longer put dollar limits on how much they’ll spend each year or over your lifetime to cover essential health benefits. [2]

4. Mental Health Coverage

Admit it — you’ve cited “mental health day” as a reason to hit the snooze button and stay home from work once or twice. For people affected by mental illness, having adequate mental health coverage for things like therapy and medication is vital to their overall wellbeing. And because we all have stressors in life and experience things that can sometimes leave us feeling hopeless, anyone covered under a major health plan will have coverage for mental health services.

5. Prescription Drug Coverage

Almost everyone will take a prescription drug at some point in their life. Whether it’s for a chronic medical condition or a seasonal bout with strep throat, prescription drugs are a standard part of medical treatment plans. Under Obamacare (or the ACA), you have the assurance that prescription drug coverage is a required benefit should you need to go to the pharmacy.

6. Rehab Services

Sometimes our emergencies are resolved when we’re discharged from the hospital, but other times they have lasting effects that require ongoing rehabilitative services. Recovering from a car accident can mean not only a night in the hospital but months of physical therapy. Because most injuries heal with time and effort, major medical insurance plans are required to cover rehab services, giving you the freedom to achieve full wellness again.

7. Lab Services

Doctors often use lab services to diagnose medical conditions and determine the right treatment plan. Laboratory services include preventive screenings and are used to gauge the effectiveness of treatments. Major insurance plans are required to cover laboratory services. However, regular copays and deductibles may apply if your laboratory services aren’t used to diagnose an illness or for preventive screenings.

8. Free Preventive Care

Research proves that regular preventive medicine is the best way to prevent and treat serious health problems. Routine screenings can save you the stress of a surprise illness and can cut the cost of your medical bills drastically. Monitoring your health is essential to your wellbeing because you’ll never know you are at risk unless you take steps to check for warning signs. Take advantage of covered preventive care services to help you find those warning signs and kickstart any necessary treatment plans.

9. Maternity and Newborn Care

The average cost to have a child in the United States is over $10,000. [3] The financial burden of uncovered maternity and newborn care can cloud a joyful season with financial stress and worry. Healthcare reform aims to make maternity and newborn care more accessible to those covered under major medical plans.

10. Pediatric Care (Including Vision and Dental)

Your child does not stop incurring medical expenses once they’re discharged from the maternity ward. As children grow, they require ongoing pediatric care. The ACA makes pediatric care an essential health benefit to all qualifying plans and includes vision and dental coverage to protect your child’s total wellbeing.

When you combine all of these services, you can quickly see how each one is essential to the maintenance of a healthy lifestyle. Requiring these components as covered benefits not only saves you money, but it gives you peace of mind.

FAQs

Are the essential health benefits the same in each state?

The short answer is yes. However, some states can require insurance companies to cover additional services and procedures. Plans can also vary within the same state. You’ll be able to compare specific benefits when you shop for plans in the Marketplace.

How can I find a health insurance plan with essential health benefits?

You can search for a plan with the Health Insurance Marketplace. All major policies will cover at least the ten essential healthcare benefits. Connect with a GoHealth licensed insurance agent to compare plans and find the right option for you.

Is hospice care considered an essential health benefit?

Yes, hospice is considered an essential benefit [4] under outpatient care. However, some plans limit the number of coverage days. Check with your insurance provider to see how much is covered on your policy, or connect with a GoHealth licensed insurance agent to learn more if you’re searching for a new plan.

Can I get health insurance coverage if I have a pre-existing condition?

Yes, you can enroll in a health plan, even if you have a pre-existing condition. Insurance companies cannot deny coverage or charge higher premiums if you have a previous medical condition at the time of enrolling in a plan. This protection is also part of the Affordable Care Act.

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