Updated: Feb 12, 2021
The Affordable Care Act (ACA) added a range of patient-friendly requirements to individual health plans. (By “individual health insurance” I mean a plan that is not provided by an employer or the government and is available to individuals not old enough for Medicare. These include coverage of pre-existing conditions, ratings not based on health conditions, and no cap on benefits paid under the plan.
The ACA also established a list of ten health insurance benefits considered to be Essential. If plans do not offer these ten essential benefits, they are not deemed to be ACA-compliant plans. Here are the ten essential health benefits of the ACA (https://www.healthcare.gov/coverage/what-marketplace-plans-cover/):
1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)
2. Emergency services
3. Hospitalization (like surgery and overnight stays)
4. Pregnancy, maternity, and newborn care (both before and after birth)
5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
6. Prescription drugs
7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Insurance companies are allowed to cover these items in different ways, but most meet the detailed requirements for each benefit. These seem like a list of benefits that would be desired or even expected of a health insurance plan. As I noted elsewhere (under 65 blog ), alternatives to ACA-compliant plans are available. These plans may be of interest to people who are between ACA open enrollment periods, or who find the monthly cost of premiums for ACA-compliant plans to be too high without the benefit of a tax credit.
When choosing these plans, think about which ACA benefits are most important to you and which you might be able to do without. Get in touch with me if you have questions about benefits or want to review your options.