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Essential Health Benefits All Qualified Health Insurace Policies Must Cover

The ACA specifies ten benefits be included in all health insurance plans sold on state exchanges beginning Jan. 1, 2014 – the date exchanges must be operational. Any new plan sold to individuals or small groups must cover the essential benefits as of Jan. 1, 2014, even if the plan is not offered through an exchange.

  1. Ambulatory patient 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 and newborn care - Care provided to women during pregnancy and during and after labor; care for newly born children
  5. Mental health and 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 and 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 and 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 and vision care - The other nine essential benefits, but provided to kids. Of course, the mix of services and common conditions treated are quite different for different age groups.

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