Just What the Heck are Essential Health Benefits? | HealthTN.com

Just What the Heck are Essential Health Benefits?

HealthTN Affordable Care Act/Obamacare

Well, funny you should ask! Healthcare.gov defines “Essential Health Benefits” as:

“The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services, preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.”

Now that is a mouthful to just say that Essential Health Benefits are sometimes different things to different people, but they all must be addressed by any policy on the marketplace. With that long definition in mind, let’s drill down into each of those categories above and clear each one up a little bit.

Ambulatory care: This kind of care, also called outpatient care, involves doctor visits that don’t require hospitalization.

Emergency services: Emergency room visits no longer require preauthorization, and you cannot be charged extra for going to an ER that’s not in your network.

Hospitalization: Hospital stays must be covered. This doesn’t mean you won’t have a copayment or have to meet a deductible, but with hospitals sometimes charging thousands of dollars a day, this benefit can save you quite a bit of money.

Lab services: Laboratory services are covered.

Maternity and newborn care: Prenatal care is now a preventive service that must be provided for free. While you’re in the hospital for labor, delivery and newborn care, both you and your baby must be covered.

Mental health and addiction treatment: Although you may have to pay copays for mental health and addiction services, and you may be limited to a certain number of appointments over a year, these services must be covered under the ACA.

Rehabilitative services: Treatment is covered for injuries or illnesses that require rehabilitation. This includes habilitative services – therapies to help overcome long-term or permanent disabilities.

Pediatric care: Children younger than 19 are covered for routine visits, well-child checkups and recommended immunizations. Under this essential coverage, they are also covered for a vision exam, eyeglasses and two dental exams.

Prescriptions: Plans must offer at least one prescription drug in every drug category.

Preventive, wellness and chronic disease treatment: Preventive care – to keep people healthy – is not only covered by your health insurance, but it’s also free because of ACA requirements.

How each of these services is covered varies widely depending on the plan and other factors, such as the network of doctors, your deductible and other out-of-pocket costs.

Confused? No need to be, what you should plan to do is read the material, then get a pro – say HealthTN.com. Of course, you can always reach out to us by phone at (615) 541-4257 to help you clear the air on what program is best for you – that’s why we’re here for you!

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