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.
The ACA defines ten essential health benefits:
- hospitalization
- 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
- pediatric services for children, including 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.