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The ACA Essential Health Benefits: Everything You Need To Know
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The Affordable Care Act (ACA) was introduced in 2014 to provide better access to health insurance in the United States, with the major goals of simplifying the American healthcare system and making coverage more reliable. To address these goals, it defined the ACA Essential Health Benefits, ten health care services that must be covered by all ACA-compliant Federal and State Marketplace health insurance plans.
The ACA Essential Health Benefits cover a wide range of important medical services. If you are interested in an ACA-compliant Marketplace plan, contact Health Care Plan Quotes for help. We can help you review your options and find a Marketplace plan that can fit your needs.
Call us at (855) 968-5736 Monday through Friday, 9 a.m. to 5 p.m. ET and our expert agents would be happy to review your ACA healthcare options. Check our free online quoting tool for ACA health coverage estimates.
What Are The Ten ACA Essential Health Benefits?
The ACA requires ten specific healthcare services to be covered by all health insurance plans offered by Federal and State Marketplaces. This list of services is known as the ACA Essential Health Benefits.
Though a health care service may be covered as one of the ACA Essential Health Benefits, that doesn’t mean your health insurance plan pays its entire cost. A Marketplace plan’s insurance tier determines covered cost percentages and copayments for ACA Essential Health Benefits services. Covered percentages vary by plan tier and provided service.
The ten ACA Essential Health Benefits are:
Ambulatory Patient Services
Ambulatory services are outpatient care at a hospital, emergency care center, or doctor’s office. Outpatient services don’t require overnight stays or admittance into a hospital.
Emergency Services
Hospitalization
ACA Essential Health Benefits cover services requiring admittance to a hospital, such as overnight hospital stays for observation, care, or surgery.
Pregnancy, Maternity, & Newborn Care
Mental Health & Substance Use Disorder Services
All Marketplace plans must cover behavioral health treatment, mental and behavioral health services at hospitals and care facilities, and substance use treatment. This includes counseling, some prescription drugs, and facility use.
Prescription Drugs
Rehabilitative/Habilitative Services & Devices
ACA plans cover services and devices intended to help people with injuries, disabilities, or chronic health conditions gain or recover mental and physical services. This includes mobility devices such as wheelchairs and crutches, speech assistance devices, and physical therapy services.
Laboratory Services
ACA Essential Health Benefits require coverage for lab services including blood and fluid tests, imaging, and biopsies.
Preventive Services, Wellness Services & Chronic Disease Management
Pediatric Services
Other Required Services
The Essential Health Benefits cover FDA-approved prescribed contraceptives for women and breastfeeding equipment. Most Marketplace plans cover counseling for women seeking birth control or pregnancy and nursing assistance.
Additional ACA Essential Health Benefits Services
ACA Essential Health Benefits are the minimum requirements for all Marketplace plans. They include few hard limits or immovable requirements so states can tailor coverage to their population’s needs.
Depending on your state, coverage specifics may vary or additional benefits, such as dental coverage, vision coverage, or medical management programs may be offered.
If you’re curious about the options for supplemental coverage in your state’s Marketplace, contact Health Care Plan Quotes. We can review your choices and help you determine what coverage fits your needs.
What Is Minimum Essential Coverage?
While they may sound similar, Minimum Essential Coverage (MEC) differs from ACA Essential Health Benefits. MEC refers to the coverage amount required to satisfy the Affordable Care Act individual health insurance mandate.
This mandate affects eligibility for ACA special enrollment periods. In some states, you may be penalized if your health coverage does not meet MEC requirements.
As a rule, all plans that cover Essential Health Benefits meet MEC requirements. However, some employer-sponsored group health plans or Medicaid plans may not.
If your previous coverage does not meet MEC requirements, you may not be eligible for a special enrollment period that you would otherwise trigger, such as a new marriage or loss of a job.
If you are curious about MEC requirements or are concerned that your health coverage may not meet them, contact Health Care Plan Quotes.
The ACA Essential Health Benefits & Enrollment Eligibiliy
You may not be eligible for certain special enrollment periods if your existing health coverage does not meet Minimum Essential Coverage requirements. However, all plans that cover the ACA Essential Health Benefits meet MEC requirements.
Minimum value is another factor that can affect special enrollment eligibility. And it’s a requirement for all health insurance, both employer and individual plans.
Minimum value is complicated, but what’s important to know is that to satisfy minimum value requirements, a plan needs to cover at least 60% of standard healthcare costs for your local area and provide “substantial coverage” for medical services.
Minimum value usually only affects employer-sponsored health insurance plans; Marketplace plans that satisfy the Essential Health Benefits nearly always exceed minimum value requirements.
MEC and minimum value requirements typically only affect special enrollment eligibility. Access to open enrollment periods is unaffected.
Conclusion
ACA Essential Health Benefits are a great basis for understanding your coverage under a Marketplace plan. The Essential Health Benefits are intentionally open-ended to allow states to tailor coverage to more accurately meet their population’s needs, so coverage varies.
Contact Health Care Plan Quotes for assistance with understanding your coverage options under ACA-compliant Federal Marketplace plans. Call us at (855) 968-5736 Monday through Friday, 9 a.m. to 5 p.m. ET and we can help find a plan that meets your needs. And be sure to check our free online quoting tool for health coverage estimates.
Frequently Asked Questions
The ten ACA essential health benefits are the minimum federally required coverage across all Marketplace plans. Some states have additional requirements for their Marketplace policies.
- Nov. 1 – Dec. 15 for coverage starting Jan. 1 the following year
- Dec. 16 – Jan. 15 for coverage starting Feb. 1 the following year
The ACA essential health benefits do not mandate dental and vision coverage. Some states mandate dental and vision coverage as additional required benefits.
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