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Thursday, March 28, 2013

10 Essential Health Benefits Insurance Plans Must Cover Starting in 2014

Alexandra Ernst

Staff Writer

Update (6/27/2017): Under the Senate Republican repeal bill, states could opt out of requiring plans to cover some or all of the essential health benefits, which are important health care services like mental health care, prescription drugs, and maternity care that all plans must cover under the Affordable Care Act. Learn more about our campaign to defend the Affordable Care Act. ​

Starting in January 2014, the Affordable Care Act will require all new individual and small group health plans (for people who don’t have traditional job-based coverage) to cover important health benefits like maternity, mental health, preventive, and pediatric dental care. These benefits, now considered “essential” by the Department of Health and Human Services, are described in final regulations the agency released last month. These essential health benefits fall into 10 categories:

  1. Ambulatory patient services (outpatient 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 (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

The Affordable Care Act’s requirement that essential health benefits be covered without annual dollar caps will provide patients with more health benefits and a lesser financial burden. While today’s plans may say they cover many of these services, actual coverage is often uneven—patients may face unexpected dollar limits on services that are technically covered by their plans, forcing them to pay the remainder of costs.

Additionally, this new definition of coverage ensures that plans cover important services that are not currently covered by many plans. People with mental health or substance abuse disorders will have the peace of mind of knowing that their plan must cover their needs and that their coverage for these mental health services must be as comprehensive as their coverage for medical and surgical services. Women can rest assured knowing that they will have maternity coverage when they become pregnant. People with developmental and intellectual disorders will benefit from habilitative services that help them learn, keep, or improve functional skills when most plans now will only cover services to regain skills. Millions of people will benefit from coverage of these essential services.

Americans have been waiting a long time for substantial coverage of services that are essential to their health. The requirement that plans cover these essential health benefits offers a pathway to comprehensive health insurance for all Americans. 

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