Since 2014, under the Affordable Care Act, all new individual and small group health insurance policies (including those sold in the ACA’s health insurance exchanges and off-exchange) must cover essential health benefits for all enrollees, without annual or lifetime caps on the amount of money the insurer will pay for the services (note that there can still be a cap on the number of covered visits; for example, an insurer might cover 20 physical therapy visits in a year, and that’s still allowed).
The ACA defines ten essential health benefits:
- ambulatory services (visits to doctors and other healthcare professionals and outpatient hospital care)
- emergency services
- maternity and newborn care
- mental health and substance abuse treatment
- prescription drugs
- lab tests
- chronic disease management, “well” services and preventive services recommended by the U.S. Preventive Services Task Force, the Health Resources and Services Administration, and the CDC’s Advisory Committee on Immunization Practices.
- pediatric dental and vision care (there is some flexibility on the inclusion of pediatric dental if the plan is purchased within the exchange)
- rehabilitative and “habilitative” services
Prior to 2014, it was common for individual market plans in many states to not include maternity benefits, prescription drug coverage, or mental health/substance abuse coverage. But since 2014, all new individual major medical plans have included these benefits — along with the rest of the essential health benefits — for all enrollees.
Grandmothered and grandfathered plans are not required to cover the ACA’s essential health benefits. Large group plans are also not required to cover essential health benefits (but if they do, they cannot impose dollar limits on the benefit).