10 Essential Health Benefits Your Insurance Plan Needs


WRITTEN BY: Craig Sturgill

UPDATED: OCTOBER 04, 2022 | 2 MIN READ

Did you know that the law requires your health insurer to cover a range of medical services? Here’s a look at your plan’s essential health benefits and why. 

What Are the 10 Essential Health Benefits?

The Affordable Care Act (ACA) lists specific health benefits for needed services. State benchmarks set coverage levels and differ by location. 

Outpatient Care

When you see the words “outpatient care” on your plan details it’s referring to doctor visits and hospital care that doesn’t require an overnight stay such as same-day surgery. Basically, outpatient means you aren’t admitted to the hospital. 

Prescription Drugs

Prescription drugs are an essential health benefit. Insurance providers must provide you with a formulary or a list of covered drugs. This list will include all drugs for which the insurer covers part of the cost. A health plan must cover at least one prescription medication in each class as determined by the government. 

Pediatric Care

Children in your family have pediatric care as an essential health benefit. Pediatric care is pediatrician visits, immunizations, plus dental and vision services. States regulate what’s considered under pediatric services.

Preventative Care

Preventative care lowers the risks of major illnesses for patients. It’s sometimcheck-upsed to as routine care, visits you make to ensure you’re in good health. Cancer screenings, flu shots, annual check-ups, and patient counseling fall under preventative care. 

Laboratory Services

Sometimes a visit to a doctor may require lab tests or diagnostic imaging. Blood and urine tests, X-rays, CT scans, and other diagnostics are essential health benefits. 

Emergency Services

If you need care for an emergency, you can go to the nearest emergency room without prior approval or worry about whether the hospital is in-network. Insurance companies may not charge you more for out-of-network visits if you suffer a true emergency, such as a stroke or a heart attack. 

Hospitalization

Care requiring hospitalization, such as surgery or car accident, is an essential health benefit. If you receive inpatient care and remain in the hospital, this falls under hospitalization. 

Mental Health Coverage

The covered essential health benefits include services for mental and behavioral health. This includes substance abuse treatment, psychiatry, counseling, and inpatient services. 

Rehabilitative and Habilitative Services

Rehabilitative services include physical therapy and are for helping you restore or improve function after a surgery, illness, or accident. Also within these essential health benefits is occupational therapy, therapists who help improve function in everyday tasks. Speech therapy also falls within this category.

Pregnancy, Maternity, and Newborn Care

If you’re pregnant, your health insurance plan must cover prenatal care, birth, and newborn care. Care options here include ultrasounds, lab tests, plus labor and delivery. Breastfeeding pumps are also covered. Like other essential health benefits, your state sets benchmarks outlining the specific guidelines an insurance plan must meet for its category.

Are Your Needs Outside Of the 10 Essential Health Benefits Still Covered By Your Insurance Company?

The state sets the specifics of your insurance company’s coverage options. No standard “yes” or “no” exists within insurance outside these essential health benefits. Your chosen health insurance plan outlines covered medical needs. Coverage varies by provider, premium, and state. For instance, your insurance plan may cover acupuncture if recommended specifically for musculoskeletal pain if doctor-ordered.

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. Unless the state requires it, health plans don’t cover male birth control methods.

A health plan must also cover pediatric dental needs for children under 19. 

Is birth control covered? If so, what kind?

Both prescription and over-the-counter birth control options are covered. Under federal law, religious-affiliated companies may refuse birth control coverage. 

State laws vary with birth control coverage options. To date, 29 states and Washington, D.C, mandate insurers to cover birth control drugs and devices. Further, 12 states and Washington, D.C., order over-the-counter birth control coverage.

Are pre-existing conditions covered?

Yes. Health insurers cover pre-existing conditions. This includes services under these ten essential health benefits. 

What Would Happen If the 10 Essential Health Benefits Weren’t Covered?

A patient might skip doctor visits if a health insurance plan lacks essential health benefits. When they seek care, they might have massive hospital bills. On average, a visit to the emergency room costs $1,273. It’s not just emergency care that may lead to financial issues and other concerns. Skipping check-ups and preventative maintenance may worsen illnesses, such as cancer or diabetes, if untreated.

Pregnancy, Maternity, and Newborns 

Pregnancy and maternity care are cornerstones of the ten essential health benefits. Prenatal care helps with pregnancy health, and studies show it’s vital. Babies born to mothers without prenatal care are five times more likely to die than mothers who have prenatal care. 

Can you get health insurance coverage with pre-existing conditions?

Yes. The ACA says that health insurance companies can’t exclude you from pre-existing conditions. Health insurers also can’t charge more for a pre-existing condition. 

What’s not considered an essential health benefit?

Cosmetic surgery and adult dental care aren’t essential health benefits. However, weight loss surgery for medical purposes might be covered. Long-term care, abortion, and vasectomies aren’t part of the essential health benefits either. Individual health insurance plans may cover these. However, insurers aren’t required to offer coverage unless under a state mandate.

What does minimum essential coverage include under the ACA?

Minimum essential coverage undecheck-upsA includes care, diagnostics, and procedures under the ten essential health benefits. Annual checkups, diagnostics, and prescriptions are all under the minimum essential coverage.

What is MEC in healthcare?

MEC stands for Minimum Essential Coverage and refers to any plan that meets the individual requirements for health coverage under the ACA. 

What are the four types of healthcare plans?

There are four types of healthcare plans: 

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Point of Service (POS)
  • Exclusive Provider Organization (EPO)

Each plan has its own providers and coverage options. 

Finding the Coverage You Need

Thanks to the ACA, health insurers must cover ten essential health benefits. Every state sets guidelines for what care falls under these benefits. It’s best to shop around for comprehensive health insurance plans. For good plans for you and your family, best sure you shop and compare rates for the best health coverage.