UPDATED: SEPTEMBER 08, 2023 | 3 MIN READ
In today’s complex healthcare landscape, grasping the significance of Essential Health Benefits (EHB) is vital when making well-informed choices about your health insurance coverage. This thorough guide will not only explain EHBs but also shed light on how they directly influence your coverage decisions, ensuring you have all the information you need to make informed healthcare choices.
What are essential health benefits?
Essential health benefits are medical services covered by health insurance plans under the Affordable Care Act (ACA). These benefits ensure that individuals and families access necessary healthcare services, regardless of their specific health needs.
The 10 Essential Health Benefits
The ACA mandates that all health insurance plans must cover these ten EHBs:
#1 Outpatient care
This includes doctor visits and hospital care that do not require an overnight stay, such as same-day surgery.
#2 Prescription drugs
Health insurance providers must offer a formulary or a list of covered drugs, ensuring access to essential medications.
#3 Pediatric care
Children in your family can access pediatrician visits, immunizations, dental, and vision services.
#4 Preventative care
Regular check-ups, cancer screenings, flu shots, and patient counseling help lower the risk of major illnesses.
#5 Laboratory services
Essential health benefits encompass diagnostic tests like blood and urine tests, X-rays, and CT scans.
#6 Emergency services
You can seek emergency care at the nearest emergency room without worrying about network restrictions or prior approvals.
Hospitalization for surgeries or accidents is a covered essential health benefit.
#8 Mental health coverage
Mental and behavioral health services, including counseling and substance abuse treatment, are included.
#9 Rehabilitative and habilitative services
This category includes physical and occupational therapy, speech therapy, and other services to help improve daily function.
#10 Pregnancy, maternity, and newborn care
Prenatal care, childbirth, newborn care, ultrasounds, and breastfeeding pumps are all covered.
Additional health insurance coverage
Beyond these essential health benefits, health insurance plans may offer additional coverage options. However, these vary by provider, state, and premium. For example, some plans may cover acupuncture for musculoskeletal pain if recommended by a doctor.
What other things must your health plan cover?
Every health insurance plan must cover female birth control. Health insurers determine coverage for specific brands and methods. Health plans don’t cover male birth control methods unless the state requires it.
A health plan must also cover pediatric dental needs for children under 19.
Birth control coverage
Under the ACA, health insurance plans are required to cover female birth control. Coverage may vary by brand and method. Male birth control methods are typically not covered unless mandated by the state.
Health insurance plans are mandated to cover pre-existing conditions, ensuring that individuals with prior health issues can access essential health benefits and receive necessary medical care.
Yes. Health insurers cover pre-existing conditions. This includes services under these ten essential health benefits.
Exclusions from essential health benefits
Certain medical services, such as cosmetic surgery, adult dental care, weight loss surgery for non-medical reasons, long-term care, abortion, and vasectomies, aren’t essential health benefits. However, depending on state mandates, some individual health insurance plans may offer coverage for these services.
Minimum essential coverage (MEC)
Understanding Minimum Essential Coverage (MEC) is essential for individuals seeking comprehensive health insurance. MEC goes beyond the surface of coverage; it ensures you have access to a broad spectrum of essential healthcare services, safeguarding both your well-being and financial stability.
What Does MEC Include?
MEC is the foundation of your health insurance, encompassing a wide array of medical services and treatments. Here’s a closer look at what MEC typically includes:
- Annual Check-Ups: Regular health check-ups are the cornerstone of preventive care. MEC ensures you have access to these crucial appointments, allowing your healthcare provider to detect and address potential health issues before they become major concerns.
- Diagnostics: Timely and accurate diagnostics are vital for diagnosing medical conditions and creating effective treatment plans. MEC covers a range of diagnostic tests, from blood and urine tests to advanced imaging like X-rays and CT scans.
- Prescription Medications: Access to prescription medications is a fundamental component of MEC. Whether you require medication for chronic conditions, acute illnesses, or preventive purposes, MEC ensures that necessary drugs are within reach.
- Preventive Services: MEC promotes a proactive approach to healthcare by covering various preventive services and screenings. This includes vaccinations, cancer screenings, and counseling services to reduce the risk of major health conditions.
- Chronic Disease Management: If you’re managing a chronic health condition such as diabetes or hypertension, MEC provides support by covering services and treatments related to ongoing disease management. This can include regular monitoring, specialized consultations, and necessary medications.
- Emergency Care: Accidents and emergencies can happen unexpectedly. MEC guarantees that you can seek immediate medical attention without worrying about whether the facility is in-network, offering peace of mind during critical situations.
The Value of MEC
MEC offers significant value in multiple ways:
- Health Maintenance: By including regular check-ups and preventive services, MEC empowers you to take control of your health and catch potential issues early, often leading to more successful treatment outcomes.
- Cost Savings: While MEC ensures access to vital services, it also minimizes the financial burden by covering many preventive and diagnostic services at little to no additional cost to you.
- Risk Reduction: MEC contributes to reducing your overall health risks by promoting preventive care and early intervention, potentially preventing the development of severe health conditions.
- Peace of Mind: With MEC, you have the confidence that your essential healthcare needs are met, allowing you to focus on living a healthier and more secure life.
Types of healthcare plans
There are four main types of healthcare plans:
Health Maintenance Organization (HMO)
- Network Restrictions: HMOs typically require choosing a primary care physician (PCP) from a network of healthcare providers. Your PCP coordinates your care and referrals to specialists.
- Referrals: In most HMOs, you’ll need a referral from your PCP to see a specialist or undergo certain medical procedures.
- Cost-Sharing: HMOs often feature lower premiums and out-of-pocket costs. However, you may have limited flexibility in choosing healthcare providers outside the network.
Preferred Provider Organization (PPO)
- Network Flexibility: PPOs offer a broader network of healthcare providers, allowing you to see specialists or seek care from any provider, both in and out of the network.
- Referrals: Generally, PPOs do not require referrals to see specialists, allowing you to seek specialized care without prior approval.
- Cost-Sharing: While PPOs offer greater flexibility, they often come with higher premiums and out-of-pocket costs than HMOs.
Point of Service (POS)
- Hybrid Model: POS plans combine elements of HMOs and PPOs. Like HMOs, they require you to choose a primary care physician, but they also offer the flexibility to see specialists outside the network.
- Referrals: Similar to HMOs, POS plans typically require referrals from your PCP for specialist visits. However, you can opt for out-of-network care with higher cost-sharing.
- Cost-Sharing: POS plans balance HMOs and PPOs regarding premiums and out-of-pocket costs.
Exclusive Provider Organization (EPO)
- Network Focus: EPOs have a defined network of healthcare providers, much like HMOs. You must seek care within this network, except in emergencies.
- No Referrals: EPOs do not require referrals to see specialists, offering flexibility within the network.
- Cost-Sharing: EPOs often feature competitive premiums but require you to pay the full cost if you seek care outside the network, except in emergencies.
Choosing the right plan type depends on your healthcare preferences, including your preferred doctors and specialists and the level of flexibility you desire. Consider factors such as network size, cost-sharing structures, and the need for referrals when evaluating these plan types. Your choice can significantly impact your healthcare experience and costs, so selecting the one that aligns with your unique healthcare needs is essential.
What are the 10 minimum essential health benefits?
The Affordable Care Act mandates that non-grandfathered health plans in the individual and small group markets must cover the following EHBs.
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
What are essential health benefits, and why are they important?
Essential health benefits are healthcare services covered by health insurance plans under the Affordable Care Act (ACA). They are important because they ensure that individuals and families access necessary medical services, promoting better health outcomes and financial security.
Can I receive coverage for birth control under my health insurance plan?
Under the ACA, health insurance plans are required to cover female birth control. However, the specific brands and methods covered may vary. Coverage for male birth control methods is typically not mandatory unless required by state law.
What happens if my health insurance plan doesn’t cover essential health benefits?
You may face financial risks if your health insurance plan doesn’t cover essential health benefits. Skipping necessary doctor visits and preventive care can lead to worsening health conditions and potentially result in higher medical costs. It’s crucial to choose a plan that includes these essential benefits.
Do health insurance plans cover pre-existing conditions?
Yes, the ACA prohibits health insurance companies from excluding individuals with pre-existing conditions or charging them higher premiums. This ensures that people with prior health issues can access essential health benefits and necessary medical care without discrimination.
Finding Comprehensive Health Coverage
Thanks to the ACA, EHBs are fundamental to health insurance plans. However, specific guidelines and coverage levels may vary by state. To find the right health insurance plan for you and your family, compare rates and options by filling out our online rate form to find comprehensive coverage.