Essential Health Benefits

 

The health insurance plans offered through the Health Insurance Marketplace and state exchanges provide minimum benefits in 10 categories, called “essential health benefits.” Each state has the ability to choose from a set of plans to serve as its benchmark plan. Whatever benefits that plan covers in the 10 categories will be deemed the essential health benefits for that state.

Below is a list of the 10 minimum essential health benefits:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

In addition, these health coverage plans:

  • Must provide free preventive care
  • Must protect your choice of doctors
  • Cannot exclude pre-existing conditions (excluding grandfathered plans)
  • Cannot charge higher premiums based on health or gender. However, rates may vary based on age, tobacco use, geography, and family size
  • Cannot have any annual benefit dollar limits
  • Cannot have lifetime benefit dollar limits
  • Cannot be rescinded by the insurer (unless fraud or an intentional misrepresentation of a material fact)
  • Must guarantee your right to an appeal

If the plan offers dependent coverage, the insurer MUST provide coverage for your child up to age 26. The child does NOT need to be your dependent on your tax return to be covered under the health plan.

 

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