Insurers must cover 10 essential benefits

Under the law, health insurers must cover 10 essential benefits.

  • Ambulatory patient services, usually referred to as outpatient care. You walk into a doctor's office, get treated, then walk out.
  • Emergency care, such as when you are struck with a sudden pain and go to the emergency room.
  • Hospitalization, though you may have to pay 20 percent of the bill or more.
  • Maternity and newborn care, including prenatal care, childbirth and infant care.
  • Mental health and substance use disorder services, including behavioral health treatment. Co-pays could be required, and the number of therapy visits could be limited.
  • Prescription drugs. Previously offered as an option at extra cost on many plans, all insurance plans must now pay for prescriptions.
  • Rehabilitative services and devices to help overcome long-term disabilities.
  • Laboratory services, including a full set of preventive screening tests such as pap smears and prostate exams. Diagnostic tests such as MRIs can require co-pays.
  • Preventive and wellness services aimed at keeping well. Insurers must provide all 50 of the preventive services recommended by the U.S. Preventive Services Task Force, such as physicals, vaccines, cholesterol screening and prostate screening.
  • Pediatric services, including dental and vision care.

What about dental and vision coverage?

Need a teeth-cleaning or eye exam? You still could be reaching into your own wallet to cover the cost even after the Affordable Care Act takes full effect next year. Dental and vision care is considered an essential benefit for children aged 18 and younger whose parents or guardians get insurance through the individual or small-group plans. The law does not mandate this coverage for adults, but some states could choose to have them covered.

Still, getting dental coverage for children and teenagers might be a bit complicated, depending on where you live. States can choose to offer those items as stand-alone plans, and federal subsidies would not help pay for the costs.

Reader Reaction
We reserve the right to remove any content at any time from this Community, including without limitation if it violates the Community Rules. We ask that you report content that you in good faith believe violates the above rules by clicking the Flag link next to the offending comment or fill out this form. New comments are only accepted for two weeks from the date of publication.