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What kind of coverage will the plans sold through the health insurance exchanges include?

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  • By
  • healthinsurance.org contributor
  • November 18, 2011

The Affordable Care Act (ACA) requires that all health insurance plans sold on state exchanges beginning Jan. 1, 2014 cover ten essential benefits:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

However, the specifics of what will be included in each of the categories have been left to individual states. Each state will choose an existing health plan to use as a model:

  • One of the three largest small-group plans in the state
  • One of the three largest state employee health plans
  • One of the three largest federal employee health plan options
  • The largest HMO plan offered in the state’s commercial market

In addition to addressing what will be covered, the ACA also broadly outlined the level of benefits – how health care costs will be split between health plans and consumers.

General percentage by level paid by consumer
(through deductibles, copays and coinsurance)

Bronze Level – 40%
Silver Level – 30%
Gold Level – 20%
Platinum Level – 10%

Read more FAQs about health reform, and essential benefits.