The 10 Essential Health Benefits of the ACA

Does Your Health Plan Have Them?

essential health benefits
All plan on the exchanges must provide 10 essential health benefits. Photo: David McNew / Getty Images

The 10 essential health benefits are services that all health insurance plans must provide to comply with the Affordable Care Act. The 10 categories are:

  1. Preventive and wellness visits, including chronic disease managementPreventive care visits have no copay. Obamacare requires that all 50 procedures recommended by the U.S. Preventive Services Task Force be covered as preventive services. These include well-woman visits, domestic violence screening, and support for breastfeeding equipment and contraception. 
  1. Maternity and newborn care. That must be provided without cost since it is preventive care.  Most young people who don't have insurance will find this is a needed benefit if they become pregnant.
  2. Mental and behavioral health treatment. It includes treatment for alcohol, drug and other substance abuse and addiction. Insurance companies avoid paying for these diseases, which need a long-term commitment. They raise co-pays to as high as $40 a session and limit the number of therapist visits.
  3. Services and devices to help people with injuries, disabilities, or chronic conditions. Most plans cover services and equipment that help you recover from temporary injuries, like a broken leg. The ACA requires coverage for equipment needed to treat a chronic disease, like multiple sclerosis.
  4. Lab tests. Plans must pay 100 percent of the cost of tests if doctors use them to diagnose an illness. Otherwise, regular copays and deductibles apply.
  1. Pediatric care. Dental and vision care must be covered.
  2. Prescription drugs. Plans must cover at least one drug in every category in the U.S. Pharmacopeia. Your out-of-pocket drug expenses count toward your deductible. That wasn't true for all insurance plans before the ACA. They also usually offered this at a cost.
  1. Outpatient care.  Most health insurance plans covered this already.
  2. Emergency Room Services. Most plans include this. Some charge extra if you go to a hospital that's out of their network, or go without pre-authorization. Obamacare plans don't charge extra.
  3. Hospitalization. Not all plans cover enough of this tremendous cost. Most people don't realize that a day in the hospital can cost between $2,000 to $20,000 a day. If you have a high-deductible plan or a one with a low maximum, you may be surprised by how much you wind up paying out-of-pocket. 

Does Your Plan Have These Benefits?

This Obamacare mandate applies to all plans created after March 23, 2010. Before then, less than two percent of plans provided all ten benefits. If you had your plan before 2010, it might be grandfathered in, and not have the required benefits.  Many insurance companies have dropped these plans. They asked you to switch to plans that do provide this coverage on the exchanges. 

Review these benefits and compare them to the benefits your plan currently provides you. You may find you can get a better plan for less money on the health insurance exchanges.  The premiums may be higher, but the coverage may wind up costing you less.

 Find out 

Obamacare allows each state to create a "benchmark" plan that will be the model for all other plans in its jurisdiction. That's to make sure the plan is not too expensive for small businesses to offer. The plans must cover the state's benchmark services without imposing a lifetime maximum, or annual limit, on costs.

Impact of the 10 Essential Benefits on the U.S. Economy

By setting this standard of benefits, the Affordable Care Act keeps insurers from cutting benefits to reduce costs. Won't they raise premiums instead? No, because millions of currently uninsured Americans will start paying premiums. 

Second, preventive care will reduce costs. That's because doctors will find and treat illnesses before they require expensive emergency room visits. Millions of families will be able to avoid bankruptcy by getting treated early, or by having the insurance to cover these expenses.

 Thanks to the Bankruptcy Prevention Act, people lost their entire life savings and homes to meet medical bills. After losing everything, they went bankrupt. As a result, medical costs are still the No. 1 cause of bankruptcy. Health care costs rose to compensate for these unpaid bills. As more people have insurance, it should lower health care costs and bankruptcies.

Third, more young and healthy people will get insurance, thanks to the maternity, newborn and pediatric care. That will reduce health insurance costs overall.

Fourth, low-income drug addicts, alcoholics, and the mentally ill will have coverage. That reduces expensive emergency room visits. That's why health care costs will rise if Trump repeals and replaces Obamacare

More on Obamacare

Pros and Cons | When Does Obamacare Start? | How Much Will Obamacare Cost Me? | How to Get Obamacare | The Truth About Obamacare | Does Obamacare Add to the Debt? | Why Reform Health Care

To save money on Obamacare, see my book The Ultimate Obamacare Handbook (2015 - 2016).