While there are many components to the Affordable Care Act (ACA), one of the most notable items is the inclusion of the Essential Benefits. As of 2014, to be considered an affordable plan under the ACA, all plans must contain the following 10 benefits:

  1. Ambulatory Services – Care you receive without being admitted to a hospital – for example, at a clinic, physician’s office or same-day surgery center.
  2. Emergency Services – Care for conditions which, if not immediately treated, could lead to serious disability or death.
  3. Hospitalization – Care you receive as a patient in a hospital, such as room and board, care from doctors and nurses, and tests and drugs administered during your stay.
  4. Maternity & Newborn Care – Care provided to women during pregnancy and during and after labor; care for newly born children.
  5. Mental Health & Substance use Disorder Services (including behavioral health treatment)– Care to evaluate, diagnose and treat mental health and substance abuse issues.
  6. Prescription Drugs – Drugs prescribed by a doctor to treat an acute illness, like an infection, or an ongoing condition, like high blood pressure.
  7. Rehabilitative & Habilitative Services and Devices – Services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills.
  8. Laboratory Services – Testing blood, tissues, etc. from a patient to help a doctor diagnose a medical condition and monitor the effectiveness of treatment.
  9. Preventive & Wellness Services and Chronic Disease Management – Preventive or wellness services include routine physicals, screening, and immunizations. Chronic disease management is an integrated approach to manage an ongoing condition, like asthma or diabetes.
  10. Pediatric Services, (including oral & vision care for children 18 and younger) – Children will be able to get their teeth cleaned twice a year, as well as receive X-rays, fillings and medically necessary orthodontia. In addition, children will be entitled to an eye exam and one pair of glasses or set of contact lenses a year.

While many employer plans cover a vast majority of these services today, these services address more specifically plans in the individual market. As many individual plans will carve out these benefits to help reign in cost to the premium.

Should you have questions regarding the ACA or your plan, feel free to email or call, Beth Cosker, CGA Benefitsbcosker@cgahealthbenefits.com  OR (206)985-2525.