10 Essential Health Benefits Under the Affordable Care Act that Insurance Plans MUST Cover
Insurance is expensive, but more people can afford health coverage due to the Affordable Care Act (ACA), also known as “Obamacare,” enacted in March 2010.
The ACA created health insurance marketplaces with financial assistance from the federal government, lowering premiums/deductibles and allowing states to open up Medicaid to eligible adults. This ensured that lower-income people had the means to access affordable healthcare coverage in the United States.
Because of this, the number of uninsured people dropped from 45.2 million in 2013 to 26.4 million in 2022, making it a historic decline. (Source: Census Bureau)
What are the Important Health Benefits Covered?
Part of the ACA (and what makes it so popular) is its requirement that all individual and small-group health plans (for those who don’t have traditional job-based coverage) cover the essential health benefits, which fall into 10 categories:
- Ambulatory patient services (outpatient services without being admitted to a hospital)
- Emergency services
- Hospitalization (surgery and overnight stays)
- Pregnancy, Maternity & newborn care
- Mental health & substance use disorder services (includes behavioral health treatment like counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services/devices (helps with injuries, disabilities, or chronic conditions to recover mental and physical skills)
- Laboratory services
- Preventive and wellness service, chronic disease management (includes vaccinations and screenings)
- Pediatric services like oral and vision care (doesn’t include adults)
This also includes birth control and breastfeeding coverage.
The above essential health benefits are just the minimum requirements. Services under each category can vary based on your state’s requirements, and they may include other benefits like dental, vision, and medical management coverage.
Spotlight on Important Services That Weren’t Covered Before
Since the ACA clearly spells out the essential health benefits that must be covered by insurance plans, important services that were often not covered by many plans are now included.
- Women can have peace of mind that they’ll have maternity coverage when pregnant.
- People with mental health or substance abuse disorders can be assured that their plan will cover mental health, medical, and surgical services.
- People with developmental/intellectual disorders will get access to habilitative services to keep, learn, or improve skills or functioning for daily living.
Preventative Health Services that the ACA Mandates
The most universal essential health benefit is preventative care. This applies to both children and adults. Some specifically for women.
For children alone, there are 29 preventative care benefits. Some include:
- Autism screening for children at 18 and 24 months
- Behavior assessments up to 17 years old
- Depression screenings begin at 12 years old
- Immunizations from birth to age 18
- Vision screening
- STI prevention counseling and screening
- Obesity screening
For adults, there are 22 preventative care benefits. Some include:
- Abdominal aortic aneurysm one-time screening for men of specific ages who have smoked
- Colorectal cancer screening for ages 45-75
- Diabetes (Type 2) screening for ages 40-70 who are overweight/obese
- Lung cancer screening for ages 50-80
- Statin preventive medication for ages 40-75 who are at high risk
For women, there are 27 preventative care benefits. Some include:
- Well-woman visits
- Birth control
- Breast cancer mammography screenings
- Cervical cancer screening for ages 21-75
- Bone density screening for ages 65+
- Folic acid supplements for women who may become pregnant
- Maternal depression screening for mothers
Finding the Right Plan for You
Let’s talk about costs. Premiums are monthly; the cost depends on which metal tier you choose based on your state and age (Bronze, Silver, Gold, or Platinum). The average national monthly health insurance cost in 2024 is $477.
If you’re ready to find the right ACA marketplace plan, you can check eligibility using the government’s or your local state’s marketplace.
Open Enrollment for the following year typically begins in November and ends in mid-January but may vary by state. So, for example, to get coverage starting January 2025, you can start enrollment as early as November 2024. You can also qualify outside of open enrollment periods, called Special Enrollment Periods, if a life event occurs (getting married, moving, having/adopting a baby, losing health coverage) or your household income falls below a certain amount.
Read More:
