Article · Health insurance
What Does Health Insurance Cover? The 10 Essential Benefits
Marketplace plans must cover ten categories of care. See what each means, and what is not on the list.
Key takeaways
- HealthCare.gov says every Marketplace plan covers the 10 essential health benefits.
- The list includes emergency care, hospital stays, prescription drugs, mental health care, maternity care and preventive services.
- Adult dental and vision coverage are not essential health benefits.
- Covered does not mean free: your deductible, copays and coinsurance still apply.
The short answer
HealthCare.gov says all plans offered in the Marketplace cover 10 essential health benefits. CMS says the Affordable Care Act requires non-grandfathered coverage in the individual and small-group markets to cover them. These are minimum requirements, and plans may offer more.
The 10 essential health benefits
| Benefit | What it covers |
|---|---|
| Ambulatory patient services | Outpatient care you get without being admitted to a hospital. |
| Emergency services | Care for medical emergencies. |
| Hospitalization | Care such as surgery and overnight stays. |
| Pregnancy, maternity and newborn care | Care both before and after birth. |
| Mental health and substance use disorder services | Including behavioral health treatment, such as counseling and psychotherapy. |
| Prescription drugs | Medicines prescribed for you. |
| Rehabilitative and habilitative services and devices | Services and devices that help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills. |
| Laboratory services | Lab tests. |
| Preventive and wellness services and chronic disease management | Care to prevent illness and manage long-term conditions. |
| Pediatric services | Including oral and vision care for children. |
Also required
- Birth control coverage.
- Breastfeeding coverage.
What is not on the list
HealthCare.gov notes that adult dental and vision coverage are not essential health benefits. A plan may still offer them, so check the plan's benefits.
What this means for you
- The list sets what a plan must cover. It does not set your cost: the deductible, copays, coinsurance and out-of-pocket maximum still decide what you pay.
- Plans differ on which doctors, hospitals and drugs they include, so check each plan's network and drug list.
- These requirements apply to individual and small-group plans. Other coverage, such as Original Medicare and Medicaid, follows different rules.
Common mistakes
- Assuming "covered" means free.
- Assuming every plan covers the same doctors and drugs.
- Assuming adult dental and vision are included.
General information only. It is not insurance, legal or financial advice. Rules and dates change and differ by state and plan, so confirm details with the official source, your insurer or your state agency.
Questions
Do all health insurance plans cover these ten benefits?
All plans offered in the Marketplace do, according to HealthCare.gov. CMS says the requirement applies to non-grandfathered individual and small-group coverage. Other types of coverage follow different rules.
Is dental insurance an essential health benefit?
Pediatric dental care is, but adult dental and vision coverage are not, according to HealthCare.gov.
Does covered mean I pay nothing?
No. Covered services can still carry a deductible, copay or coinsurance, depending on your plan.
Sources
- HealthCare.gov: What Marketplace health insurance plans coverhealthcare.gov
- CMS: Information on Essential Health Benefits (EHB) benchmark planscms.gov
Informational only. Rules and policy terms change and differ by state and insurer. Confirm details with your policy, your insurer or your state insurance department.
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