Before the Affordable Care Act, insurers could deny coverage to people who had pre-existing medical conditions or used too much medical care. Now, all ACA-compliant health plans are required to help all their enrollees pay for certain medical services, no matter their health status or which plan they buy. This is called minimum essential coverage.
How Does Minimum Essential Coverage Work?
In order to be considered minimum essential coverage, all health plans, regardless of price, insurance company, or metal tier, cover ten essential health benefits (we’ll get into those later). How much of these benefits they cover depends on your plan’s actuarial value.
The percentage of total average costs for covered benefits your health insurance plan will pay for
Your plan’s actuarial value is determined by its metal tier. Because you pay more each month for health plans in higher metal tiers, insurance companies are willing to cover more of your medical costs. Here’s how actuarial value breaks down by plan type:
Keep in mind: actuarial value takes into account the total cost of your benefits. This does NOT mean your insurance company will pay 60 percent for every individual service (psst: some care is even free!). What you’ll owe for different services depends on your deductible and out-of-pocket max.
What Are the 10 Benefits My Plan Will Cover?
Every health plan must help pay for ten essential health benefits (EHBs). This allows you to get better access to affordable health care, and doesn’t leave you paying budget-busting prices for services you really need. Covered EHBs include:
- Laboratory services, including diagnostic lab tests and some preventive screening tests (e.g. diabetes or cholesterol screenings).
- Emergency services: Your insurer will help pay for emergency care at a hospital, even if you are at a facility that’s out of network.
- Prescription drugs: Medications are categorized by tiers, and within each tier is at least one drug that your insurer has to help pay for. Keep in mind: that means similar medications may not be covered.
- Mental health / substance abuse: Your plan includes coverage for your emotional and psychological well-being, including counseling, psychotherapy, mental health inpatient services, and even treatment for substance abuse.
- Maternity and newborn care, including a variety of services that take care of you and baby during pregnancy, delivery, and post-delivery.
Inside Tip: You can switch plans when you have a baby! Consider buying an expensive plan that covers more of your pregnancy medical costs, then switch to a more affordable option once you’re out of the hospital and those big medical bills are behind you.
- Pediatrics services, including oral and vision care: If you have children included on your health plan, your insurer will help cover many services that keep them healthy. This includes routine dental checkups, yearly eye exams, vaccinations, and well-child visits.
- Rehabilitative and habilitative services and devices: Designed for people with disabilities, injuries, or chronic conditions, this EHB includes coverage for physical, occupational, and speech therapy visits.
- Ambulatory patient services: These are services you get at outpatient care, which is a medical facility that doesn’t keep you overnight after a procedure.
- Preventive / wellness services and chronic disease management: Preventive services help you stay on top of your health, and are 100 percent covered by ALL plans. This means you can get certain cancer screenings, annual checkups, and much more at no cost.
- Hospitalization: If you are in the hospital for inpatient care (you’re staying overnight), your plan will help pay for your medical bills. Keep in mind that your plan may only cover you for a certain period of time.