Essential Health Benefits

Services that Marketplace health insurance plans must cover

Essential Benefiits Image

Under the Affordable Care Act, Marketplace plans must provide coverage for the following health benefits:

  • Outpatient services (care you get without being admitted to a hospital)
  • Emergency services – in an emergency, your insurance company can't charge you more for getting emergency room services at an out-of-network hospital
  • Hospitalization – such as surgeries and overnight stays
  • Pregnancy, maternity and newborn care – both before and after birth, even if your pregnancy begins before your coverage takes place
  • Mental health and substance use disorder services, including behavioral health treatment – your insurance company can provide a list of what your specific health plan covers
  • Prescription drugs
  • Rehabilitative and habilitative services and devices – to help people with disabilities, injuries or chronic conditions gain or recover mental and physical skills
  • Laboratory services
  • Preventive and wellness services and chronic disease management, such as, shots and screening tests – these services are free only when delivered by a doctor or other provider in your health plan's network
  • Pediatric services for children, including dental and vision care

Additional benefits include birth control and breastfeeding coverage. Some plans may offer additional benefits including adult dental and vision care. Check with your insurer to confirm what your plan offers.

In 2018, the Centers for Medicare and Medicaid finalized a rule allowing states to determine the minimum essential health benefits that individual and small business health plans operating in the state are required to cover, beginning in 2020. This flexibility means that essential health benefits can vary from state to state. In an effort to address the opioid epidemic in our country, Illinois now requires insurers to cover alternative therapies for chronic pain, issue short-term prescriptions for chronic pain and remove barriers to medication-assisted treatment for opioid use disorders. The state also expanded access to mental health services through telepsychiatry.

Specific services may vary based on each state's requirements and you should refer to your insurer and health plan to confirm your exact coverage.