Essential health benefits

One of the biggest upsides of the Affordable Care Act (opens in new tab) (ACA) is that it requires all insurers to cover a minimum level of care for everyone. These "essential health benefits" ensure that most health care you need will be covered by your plan.

What are the essential health benefits?

All qualified health plans selling individual health insurance on the health care exchanges in any state must offer this basic benefits coverage. In other words, any and all health plans sold through the marketplace will cover at least these benefits.

The following services must be covered (in full or in part) by all plan types:

• Ambulatory (or “outpatient”) services: Any medical care you receive where you aren’t admitted to a hospital.
• Emergency services: Medical care that you receive when visiting an emergency room, whether for a broken arm or a heart attack.
• Hospitalization: Any reason you’re admitted into a hospital, including for surgery or overnight observation.
• Maternity and newborn care: All of your practitioner provider visits during your pregnancy as well as your birth and doctor visits for your newborn baby.
• Mental health and substance use services: Psychiatrist or counselor care as well as treatment at a mental health clinic.
• Prescription drugs: Antibiotics, blood pressure drugs, antidepressants, and all other medications prescribed by your doctor.
• Rehabilitative services and devices: All medical care you get for an injury, disability, or chronic condition (like physical and occupational therapy, speech therapy, psychiatric rehabilitation, etc.).
• Laboratory services: Any time a practitioner takes a sample (blood, urine, skin, etc.) and sends it to a lab for testing.
• Preventive care, wellness services, and chronic disease management: Visits to your doctor for your annual checkup, vaccines, or screenings (such as blood pressure, cholesterol, or colon cancer), along with medical care for chronic diseases (like diabetes, heart disease, cancer, or arthritis).
• Contraceptives: Many forms of birth control including the pill, implants, IUDs, emergency contraception, sterilization procedures for women, and more, as well as counseling from your doctor.
• Pediatric services: All health care for kids, including dental and vision.

Are these the only benefits on my health insurance plan?

The above aren’t necessarily the only benefits your plan offers. Certain benefits are only covered on some plans, while others are only required in select states. Not sure what else your plan includes? Check online or call your health insurance provider to confirm what other benefits you get. If you're an Oscar member, just log in (opens in new tab) or call our concierge team at 1-855-672-2755.

How much do I have to pay?

Every health service you get that’s considered an essential benefit by your qualified health plan will either be covered or covered-in-full (opens in new tab). If the service is covered-in-full, your insurer will pay for all of it. If it’s covered, you will pay a portion or all of the bill depending on your plan and the services you received. Any money you pay for a covered benefit will count toward your out-of-pocket max (opens in new tab).