What Do Affordable Care Act Plans Cover?

The Affordable Care Act (ACA) is a federal law that was signed into action in 2010. This comprehensive health program has three main goals:

  • Make it easier for people to get access to affordable health insurance
  • Expand and improve Medicaid 
  • Support medical innovations and delivery of medical care to reduce costs further

ACA health plans can be purchased from a national marketplace for those who reside in 33 states. Residents of the District of Columbia and the remaining 17 states have separate ACA marketplaces.

10 Essential Health Benefits 

All ACA marketplace health plans must include ten essential medical services as well as dental plans for children. The ten essential health benefits that all ACA marketplace plans are required to cover are as follows:

  • Preventive care, chronic disease management, and wellness services
  • Pediatric services (including vision and oral care)
  • Hospitalization (inpatient care and surgeries)
  • Outpatient care
  • Emergency services
  • Prescription drugs
  • Lab services
  • Maternity, pregnancy, and newborn services (includes prenatal, childbirth, and postnatal care)
  • Rehabilitative and habilitative devices and services (to help patients recover or gain new skills after an injury or amid disability or chronic conditions)
  • Mental health and substance use disorder services (including behavioral health treatments, such as counseling and psychotherapy)

ACA marketplace plans are also required to provide breastfeeding coverage and birth control coverage (certain religious employers are exempt from this rule).

Additional ACA Benefits

While the ten essential health benefits above are a minimum requirement, many plans have additional benefits. These include:

  • Vision coverage
  • Dental coverage
  • Medical management programs for conditions such as diabetes, back pain, and weight management

Be sure to compare plans while browsing the marketplace to see which additional benefits (if any) are offered. 

Out-of-Pocket Costs

Most ACA health insurance plans require members to pay a monthly premium and may have more out-of-pocket costs that members must cover when they receive care. These charges will likely need to be covered anytime you’re using a provider outside your coverage network for services outside of preventative care. 

It’s also worth noting that when you receive any of the essential health benefits listed above, you will probably also have some form or combination of deductibles, copayments, coinsurance, and out-of-pocket maximums to cover.  

In some cases, private health insurance can be more beneficial, so it’s worth considering if you haven’t chosen a plan yet. 

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