Here is what health insurance covers on every ACA plan: 10 groups of essential health benefits, from doctor visits and hospital stays to prescriptions, mental health care and maternity care. Plans also cover many preventive services at $0 from in-network providers. However, adult dental and vision care usually need a separate plan, and costs depend on your network.
- Every Marketplace plan must cover 10 categories of essential health benefits, including emergency care, hospital stays, maternity care and prescriptions.
- Many screenings and vaccines cost you $0 from an in-network provider, even before you meet your deductible.
- Insurers can't set yearly or lifetime dollar limits on essential health benefits.
- Your plan can't charge you more for emergency room care at an out-of-network hospital.
- Adult dental and vision care aren't essential benefits, so most adults need a separate plan for them.
What health insurance covers: the 10 essential health benefits
The ACA sets a floor for what health insurance covers. All Marketplace plans must include these 10 groups of services, called essential health benefits. Think of them as the minimum, since many plans add more.
- Outpatient care, such as doctor visits and same-day procedures
- Emergency services, even at an out-of-network hospital
- Hospital care, such as surgery and overnight stays
- Pregnancy, maternity and newborn care
- Mental health and substance use disorder services, such as counseling
- Prescription drugs, as long as they are on the plan's drug list
- Rehab and habilitative services and devices, such as physical therapy
- Lab tests, such as blood work
- Preventive and wellness care, plus chronic disease management
- Pediatric services, including dental and vision care for kids
On top of these, plans must cover birth control and breastfeeding support. Still, the exact services inside each group can vary by state. So read your plan's own benefit list, and learn how claims move in our guide to coverage in action, from visit to bill.
Protections built into every plan
Coverage is more than a list of services. In addition, federal rules protect you in ways that matter most in a bad year. Here are the numbers to know for ACA plans.
- Insurers can't set yearly or lifetime dollar limits on essential benefits.
- Also, insurers can't turn you down or charge more for a pre-existing condition.
- Pregnancy and childbirth get coverage from the day your plan starts.
- After you enroll, your rate can't rise just because your health changes.
One caution: grandfathered plans don't have to follow every rule. Ask your carrier if you're unsure. Your next step: find the out-of-pocket maximum on your plan summary.
Preventive care at $0 in network
Most health plans, including Marketplace plans, cover a set of preventive services at no cost to you. That means no copay or coinsurance, even before you meet your deductible, as long as an in-network provider does the service. Here are some examples from HealthCare.gov.
For adults
For example, adults can get blood pressure, cholesterol and depression screening. Also, colorectal cancer screening covers adults 45 to 75, and hepatitis C screening covers adults 18 to 79. In addition, lung cancer screening covers adults 50 to 80 at high risk. Routine vaccines, such as flu, tetanus and shingles, are on the list too.
For women
Women also get a yearly well-woman visit. Plus, mammograms every 1 to 2 years are part of the list for women 40 and older. Likewise, cervical cancer screening applies to women 21 to 65.
For children
Children get well-baby and well-child visits from birth to 18, as well as vision screening. In addition, fluoride varnish starts once teeth appear. Autism screening also happens at 18 and 24 months.
HealthCare.gov notes that $0 isn't promised in every case. For example, a preventive service from an out-of-network provider usually costs you. Also, the age and risk rules above decide who qualifies. So ask your provider to confirm the visit will bill as preventive care.
A licensed Vivna agent can read any plan's benefits with you and point out the gaps, at no cost to you.
How health insurance covers everyday care, emergencies and drugs
Beyond preventive care, you usually share costs. You may pay a copay, a flat fee, or coinsurance, a percentage, often after your deductible. Our guide to flat fees and percentages compared shows the math.
Doctor visits and hospital stays
Office visits, urgent care and specialist visits fall under outpatient care. Usually, you pay a copay for each one, or coinsurance after your deductible. Some plans, such as many HMOs, also need a referral before you see a specialist.
Hospital stays and surgery work differently. First, you pay toward your deductible. Then you pay coinsurance until you reach your out-of-pocket maximum. After that, the plan pays 100% of covered in-network care for the rest of the year. So a big bill has a ceiling, even when it feels endless.
Emergencies
In a true emergency, go straight to the hospital. Insurers can't require prior approval for emergency room services. Plus, your plan can't charge you more at an out-of-network hospital, though your deductible may still apply.
Prescriptions
Each plan lists covered drugs on its formulary, sorted into price tiers. Generics usually cost the least. Meanwhile, some drugs need prior authorization, so check each one by name before you enroll.
What health insurance usually doesn't cover
Knowing what health insurance covers also means knowing what it leaves out. Watch for these common gaps when you compare plans.
- Adult dental care, which most plans leave out
- Vision care for adults, since only some plans include it
- Cosmetic procedures, unless they are medically necessary
- Drugs off the formulary, unless you win an exception
- Non-emergency care outside the network on an HMO or EPO
For teeth and eyes, look at our dental and vision plans for adults. Also, a medical plan doesn't replace lost income during an illness. Instead, our guide to accident, hospital and critical illness add-ons explains extra cash benefits that sit on top of your main plan.
Staying healthy with your benefits
Your benefits work best when you use them before you get sick. So build a few habits into your year. Each one uses coverage you already pay for.
- Pick a primary care doctor
One doctor who knows you can coordinate care and referrals. Read our tips on finding a doctor you can stay with.
- Book your yearly checkup
Schedule it in the same month every year, and ask which screenings are due.
- Stay current on vaccines
Flu shots and other routine vaccines often cost $0 in network.
- Try virtual visits
Video or phone care can handle many minor issues. See our guide to getting care by video or phone.
- Keep kids on schedule
Well-child visits and screenings are part of every plan. Learn more about coverage options for your children.
The cheapest care you will ever get is the checkup you already paid for.The rule our licensed agents repeat most
How to check what your health insurance covers
Every plan is a little different. Fortunately, three documents tell you what your health insurance covers before you enroll.
- Read the Summary of Benefits and Coverage, a short, standard summary every insurer must provide.
- Search the formulary for each of your prescriptions, and note the tier.
- Confirm your doctors on our Find a Doctor in My Network page.
Turn to the coverage examples near the end of the Summary of Benefits and Coverage. They show what the plan would pay for situations such as having a baby or managing diabetes. Then compare those examples across two plans, because they use the same format.
Also, learn to read each number on your ID card. To compare plans, browse our ACA and private medical plan options, or call a licensed Vivna agent at 888-730-6001.
What health insurance covers: FAQs
What does health insurance cover by law?
Marketplace plans must cover 10 essential health benefits. These include outpatient care, emergencies, hospital stays, maternity care, mental health care, prescriptions, rehab, lab tests, preventive care and pediatric care. Plans must also cover birth control and breastfeeding support. The exact services within each group can vary by state.
Is preventive care really $0 with health insurance?
Often, yes. Most plans cover a set of preventive services, such as many screenings and vaccines, with no copay or coinsurance from an in-network provider. That's true even before you meet your deductible. However, HealthCare.gov notes that $0 isn't promised in every case, so confirm with your provider first.
Does health insurance cover dental and vision?
For children, yes, because pediatric dental and vision care are essential benefits. For adults, usually not. Adult dental and vision care aren't essential benefits, and only some medical plans include them. So most adults add a separate dental plan, vision plan or combined dental and vision plan.
Does health insurance cover emergencies out of network?
Yes. Emergency services are an essential benefit. Your plan can't require prior approval for emergency room care, and it can't charge you more at an out-of-network hospital. Still, your deductible and normal cost sharing may apply. In a true emergency, go straight to the nearest hospital.
Can a licensed agent explain my benefits?
Yes. A licensed agent can walk through any plan's benefits, drug list and network with you. Vivna's agents compare plans from 50+ carriers, such as UnitedHealthcare, Ambetter and Oscar, at no cost to you. Call 888-730-6001 Monday through Friday, 9am to 6pm.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- HealthCare.gov: What Marketplace health insurance plans cover
- Preventive health services, from HealthCare.gov
- HHS: Lifetime and annual limits
- HealthCare.gov: Coverage for pre-existing conditions
- Getting emergency care, from HealthCare.gov
- HealthCare.gov: Summary of Benefits and Coverage
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time.