What are Essential Health Benefits

What are Essential Health Benefits

The Affordable Care Act’s (ACA) “Essential Health Benefit” rule forces insurers selling individual and small group plans to cover 10 categories of “essential” medical services. Prior to ACA mandating essential medical services, only approximately 2% of individual and small group plans were providing for coverage for all ten.  One warning; there are several plans that are available to consumers that have been “grandfathered” that do not have the mandated benefits.  All plans sold after January 1, 2014 has mandated benefits.  The coverage level for each of these services varies widely from plan to plan.  Remember, deductibles, co pays, etc. could apply.  The table below outlines the 10 “essential;” benefits:

1.     Ambulatory patient 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 services and devices
8.    Laboratory services
9.    Preventive and wellness services and chronic disease           management
10.  Pediatric services, oral and vision care

The above list outlines generic categories. To secure specific information about each category, contact your Healthcare Insurance Company or your Human Resource Department.

Many consumers have this span of coverage with their large group plans.  The ACA is leveling the playing field by mandating the coverage for all consumers.

The consumer can and should take advantage of Essential Health Benefits that are outlined in their health insurance plans.  In general, some plans offer these services without the consumer cost sharing meaning that the deductible, co pay, etc…may not apply.  The savvy consumer should research their insurance plans to optimize the benefits offered.

Consumer should be aware of the following:

  1. Your medical service maybe covered as an Essential Health Benefit but you doctor may order tests that are covered differently. Ask your physician to make sure they are included.
  2. Many billing errors occur. If you receive an explanation of benefits (EOB) not covering the full amount of the essential health benefit, call your insurance company and appeal the claim.  If you receive a bill form your doctor, match up the bill with your EOB to determine if the insurance claim was processed correctly. If processed incorrectly, appeal the claim.
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