Mike was feeling a bit overwhelmed as he began to think about all of the preventive tests that come with turning 50. He knew that he had to stay on top of those tests because of his family's history with cancer, but he also knew that he couldn't afford to do all of them out of pocket. When he signed up for health coverage through the ACA Exchange, he read that preventive services were included at no out of pocket costs to him. But he couldn't figure out what exactly that meant.
Mike's doctor had recommended that he should take advantage of a cancer screening test, and now he was trying to determine if this test was included in his plan. The cost of a colonoscopy is not small, and he was afraid he would be hit with an unexpected bill. Like many Texans, Mike wanted to make the most of his ACA health plan, but understanding the specifics of what’s covered can be tricky.
If you’re like Mike and wondering what services are fully covered under your ACA health plan, you’re not alone. One of the key aspects of ACA policies is that they come with a set of essential health benefits—a collection of services that every ACA-compliant plan must cover. But what exactly are these benefits, and how do they affect your coverage in Texas?
What Are Essential Health Benefits?
While Mike, like most Texas residents, was truly concerned about getting quality health care, he knew that he had a lot more at risk than just the cost of his monthly premium. He wanted to understand his costs as well as what was included in his health insurance coverage. Essential health benefits are a set of ten categories of services that ACA plans that must be covered by health insurers. These benefits ensure that individuals and families have access to necessary medical care without the fear of gaps in coverage.
While all ACA-compliant plans must cover these medical services, how much you pay for each service (through copays, deductibles, and coinsurance) can vary depending on the type of plan you have. Understanding these benefits can help you make informed decisions about your healthcare and make sure you’re leveraging everything your health insurance policy has to offer.
The 10 Essential Health Benefits Required by ACA Plans in Texas
1. Ambulatory Patient Services
This category covers outpatient care you receive without being admitted to a hospital. Whether it’s a doctor’s office visit or a simple outpatient surgery, these services are included in your plan’s benefits. Mike, for example, was able to see his primary care doctor for annual check-ups, all covered under his ACA plan. Some of these visits do involve payment on your end, but you cannot be denied coverage as long as you are seeing a network provider.
2. Emergency Services
Emergency room visits and ambulance services fall under this benefit. The best part? You don’t need prior authorization, and coverage applies even if the hospital is out of your network. Whether you’re in Abilene or elsewhere, this gives you peace of mind in a real emergency. Mike understood that he would be paying for a portion of these medical costs.
3. Hospitalization
If you’re admitted to the hospital for treatments, surgeries, or other procedures, this benefit comes into play. Everything from an overnight stay to major surgery is covered under this category, although the costs can vary based on your deductible and copays.
4. Maternity and Newborn Care
Expecting parents will be glad to know that ACA plans include maternity care, which covers prenatal visits, labor, and delivery, as well as postpartum care. This also extends to care for your newborn during the hospital stay and afterward including the NICU if it is required.
5. Mental Health and Substance Use Disorder Services
Mental health care is just as important as physical health, and ACA plans recognize that. This benefit covers mental health services like counseling, therapy, and treatment for substance use disorders. Mike’s wife was able to get therapy sessions covered as part of their ACA plan though it was subject to their deductible.
6. Prescription Drugs
Every ACA plan must cover at least one medication in each therapeutic class, ensuring that you have access to necessary prescription drugs. The specifics of your drug coverage will depend on your plan’s formulary (the list of covered drugs), so it’s a good idea to check which medications are included and how much the out of pocket costs will be for your health insurance coverage.
7. Rehabilitative and Habilitative Services and Devices
These services help you recover from an injury, illness, or disability (rehabilitative services), or help you gain or maintain skills necessary for daily living (habilitative services). This benefit also includes medical devices such as crutches, wheelchairs, and walkers as part of your health care services. These services are usually subject to their own special copays or rules about percentage of costs.
8. Laboratory Services
Lab tests are a big part of preventive care. Marketplace plans cover lab work, such as blood tests and diagnostic screenings, and preventive screenings like cholesterol or cancer tests often come with no out-of-pocket costs. Mike, for example, was able to get his cholesterol screening without having to pay a copay because it was classified as preventive care.
9. Preventive and Wellness Services, and Chronic Disease Management
Preventive care services—such as vaccines, screenings, and wellness visits—are covered at no cost to you. This is where Mike was able to benefit since his colonoscopy was covered under the schedule of preventive tests that did not require a deductible or to pay a copay. It's also important to realize his cholesterol screening were included under this essential benefit as well. Managing chronic diseases, like diabetes or high blood pressure, is also included, helping Texans stay on top of long-term health conditions.
10. Pediatric Services, Including Dental and Vision Care
For families with children, this benefit ensures that pediatric services, including dental and vision coverage, are part of your ACA coverage. This includes routine check-ups, dental cleanings, and eye exams for children under the age of 19.
Why Are Essential Health Benefits Important for Texans?
Essential health benefits protect Texans from having coverage that leaves out necessary services, such as hospitalization or preventive care. These benefits help eliminate surprise medical bills for regular health care needs and allow you to plan your costs of health services with confidence.
Also, these standardized benefits across ACA plans help you compare individual policies easily. When you know each plan must cover these ten categories, you can focus on other factors like premiums, deductibles, out of pocket limits, and network coverage when choosing a plan.
How Essential Benefits Affect Your Choice of ACA Plan in Texas
All ACA plans in Texas must cover the 10 essential health benefits, but the way they cover these services varies depending on the type of plan you choose—Bronze, Silver, or Gold. While the benefits themselves are the same, how much your costs of health services like hospitalizations or prescriptions will be for each event. This makes it important to review the cost-sharing details of any qualified health plan you’re considering to make sure it fits your needs.
For example, if you expect to use mental health services frequently, choosing a plan that offers lower copays for counseling might be a better fit. On the other hand, if you rarely visit the doctor, you might prefer a plan with lower premiums and higher deductibles for hospital care.
Insurance For Texans Has Alternative Health Insurance Options
Essential health benefits are a great starting point, but there are other health insurance options that might be a better fit depending on your specific needs. The experienced health insurance agents at Insurance For Texans have access to different plans to customize a solution for your family.
Since we live in Texas, work with Texans, and have specialists that help Texas families obtain the health insurance coverage that is right for them, we make a great partner for your view into the health insurance marketplace. In addition to ACA-compliant plans, you can also explore over types of health insurance policies that provide unique ways to provide covered health care services.
- Catastrophic Health Insurance Plans: Designed for those seeking protection against major medical events with lower premiums.
- Short-Term Health Plans: Temporary solutions for those between jobs or waiting for other coverage.
- Health Sharing Ministries: For people who prefer to share medical expenses within a community, though eligibility requirements apply.
Whatever your needs are, it’s important to assess them carefully and work with an experienced health insurance agent who can help you find the right solution.
Understanding the essential health benefits that come with ACA plans can help you make the most of your coverage. From preventive care to hospital stays, these benefits ensure that you and your family have access to the services you need.
Contact Insurance For Texans today to learn more about ACA health plans and find the right coverage that fits your essential health care needs.