What Services Do Marketplace Health Insurance Plans Cover?
What exactly does my health insurance cover?
Shanti
9/25/20262 min read
What Services Do Marketplace Health Insurance Plans Cover?
One of the most important questions when choosing health insurance is:
What exactly does my health insurance cover?
All health insurance plans offered through the Health Insurance Marketplace must cover a set of essential healthcare services known as Essential Health Benefits.
This requirement applies to all plan categories, including Bronze, Silver, Gold, Platinum, and Catastrophic plans.
10 Essential Health Benefits Marketplace Plans Must Cover
1. Outpatient Care
Services you receive without being admitted to a hospital, including many doctor visits and outpatient medical services.
2. Emergency Service
Medical care needed in emergency situations.
3. Hospitalization
Services such as surgery, hospital stays, and overnight hospital care.
4. Pregnancy, Maternity, and Newborn Care
Care related to pregnancy, childbirth, and the health of both the mother and baby before and after birth.
5. Mental Health and Substance Use Disorder Services
This may include behavioral health services, counseling, psychotherapy, and treatment for substance use disorders.
6. Prescription Drugs
Marketplace plans must provide prescription drug coverage. However, the list of covered medications and the amount you pay for each medication can vary from one plan to another.
7. Rehabilitative and Habilitative Services and Devices
These services and devices help people recover, develop, or maintain physical and mental abilities after an injury, illness, disability, or chronic health condition.
8. Laboratory Services
Laboratory tests and other related services used to diagnose, monitor, and treat medical conditions.
9. Preventive Services and Chronic Disease Management
Preventive care, routine screenings, and certain preventive services may be available without out of pocket costs when specific requirements are met.
Management of chronic health conditions is also included among Essential Health Benefits.
10. Pediatric Services
Healthcare services for children, including pediatric dental and vision care, are included among Essential Health Benefits.
It is important to note that adult dental and vision coverage are not considered Essential Health Benefits, although some health plans may offer these benefits.
Do All Marketplace Plans Provide the Same Coverage? No.
Although all Marketplace plans must cover the main categories of Essential Health Benefits, the specific details of coverage can vary depending on the plan and state requirements.
Some plans may also offer additional benefits, such as adult dental or vision coverage or programs designed to help manage conditions such as diabetes, back pain, or weight management.
Does Covered Mean Free?
No. This is an important point to understand when choosing health insurance.
Just because a healthcare service is covered by your insurance does not necessarily mean that your insurance company will pay the entire cost from the beginning.
Depending on your plan, you may be responsible for a Deductible, Copay or Coinsurance when receiving medical services.
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