What it Covers

Health insurance coverage is now much more standardized than it used to be. In the past, many plans did not cover important services, such as childbirth or mental health services. Now, all individual plans must cover a set of benefits which are called Essential Health Benefits (EHBs).

All individual health coverage options must cover your needs when it comes to these Essential Health Benefits. The biggest thing that will vary is how much you’ll have to pay, which we’ll look at later; and even then, there are limits to how much your insurance can charge you for your care.

Essential Health Benefits

These are the Essential Health Benefits that all plans must provide:

• Ambulatory patient services (care you get without being admitted to the hospital)
• Emergency services
• Hospitalization
• Maternity and newborn care (care before and after your baby is born)
• Preventive and wellness services and chronic disease management, including:
  • Immunization vaccines for many diseases
  • Screening for different conditions
  • Counseling for some health issues
  • Women’s preventive care
  • Children’s preventive care
• Prescription drugs
• Laboratory services
• 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)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Pediatric services for children, including oral and vision care

Non-Essential Health Benefits

There are some types of health care that plans are not required to provide. Here are some examples of services that may not be covered:

• Fertility treatments
• Cosmetic surgery (unless medically necessary)
• Dental care for adults
• Vision care for adults
• Alternative medicine such as acupuncture

There may be individual plans you can get that cover these items. However, no plan is required to provide them and the plans that do offer them will be more expensive.

Differences Between Plans

Plans you can get through HealthCare.gov all offer the same Essential Health Benefits. The real differences between plans are whether they offer non-essential benefits, which doctors you are allowed to visit, how much your monthly premium is, and how much you have to pay each time you visit the doctor or need another medical service.