Các kế hoạch bảo hiểm sức khỏe của thị trường, được cung cấp thông qua các thị trường bảo hiểm sức khỏe được thành lập dưới Đạo luật Chăm sóc Sức khỏe Hợp lý (ACA), thường bao gồm một loạt các dịch vụ và quyền lợi sức khỏe cơ bản. Mặc dù các chi tiết cụ thể có thể thay đổi theo từng kế hoạch và vùng địa lý, dưới đây là các loại dịch vụ và quyền lợi thường được bảo hiểm bởi các kế hoạch bảo hiểm sức khỏe của thị trường:
What Marketplace health insurance plans cover
Marketplace health insurance plans, which are available through the health insurance marketplaces established under the Affordable Care Act (ACA), commonly cover a range of essential health services and benefits. While the specifics can vary by plan and location, here are the categories of services and benefits that are typically covered by marketplace health insurance plans:
It’s important to note that while marketplace plans must include essential health benefits, the specifics can vary between plans and by state. Policyholders should carefully review the details of each plan to understand the covered services, any cost-sharing requirements (like copayments, deductibles, and coinsurance), and the network of healthcare providers.
When shopping for a marketplace plan, individuals and families can use the marketplace’s website or resources to compare plans and find one that best suits their healthcare needs and budget.
What Marketplace health insurance plans cover
All plans offered in the Marketplace cover these 10 essential health benefits:
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Hospitalization (like surgery and overnight stays)
Pregnancy, maternity, and newborn care (both before and after birth)
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
Prescription drugs
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)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Preventive Services
are free, and some plans cover other services without out-of-pocket costs.
There are 3 sets of free preventive services. Select the links below to see a list of covered services for each group:
Additional services
Dental: Your health insurance does not have to offer dental care for adults. However, insurers must offer dental coverage for children. If you buy insurance through the Marketplace, this may be part of your regular health plan. Or you may have to buy a stand-alone dental plan if you want coverage for your children. It’s up to the states to decide whether to require parents to buy these plans for their children.
Vision: You’ll find the same limits on vision care as on dental care. Insurance companies don’t have to offer vision coverage for adults, but they do for children. You might have to buy a stand-alone vision plan to cover your children in some states.
Medical management programs (for specific needs like weight management, back pain, and diabetes) When comparing plans, you’ll see exactly what each plan offers
Cosmetic surgery: Most insurance plans did not cover cosmetic surgery before the Affordable Care Act, and that hasn’t changed. But some plans do cover plastic surgery if it’s needed for a medical reason. For instance, if you have a baby born with a birth defect, your insurance might cover it.
Substance abuse counseling: This is considered an essential health benefit that insurers must cover.
Weight-loss surgery: This depends on the state. Nearly half of the states cover weight loss surgery. Check with your state’s Marketplace to find out.
Breastfeeding: Any plan bought through a Marketplace, on the individual market, or through your small employer must offer breastfeeding support, counseling, and equipment. Your plan must cover the cost of a breast pump, but your insurance company can decide whether to buy you a new one or rent one for you, and specify the kind of pump you can get.
Home health care: All states include home health care in their definition of essential health benefits. Home care may be subject to limits on the number of visits.
Chiropractic care: Most states cover this type of care, but check with yours to make sure. In some states, your insurance must pay for a chiropractic doctor who provides medical services that are essential health benefits.
Acupuncture: Only a handful of states cover acupuncture. Check with your Marketplace.
Male contraception: Birth control for women is covered at no cost to you. Male contraception, such as a vasectomy, condoms, or other methods, is not.
Psychotherapy: Mental health benefits are considered an essential benefit and are covered. The law also requires that mental health benefits be equal to a plan’s coverage of medical or surgical care.
Long-term care: You will need to pay for long-term care if you become disabled or need to move to a nursing home. It’s not an essential health benefit under the Affordable Care Act and is not covered by Medicare or most private health plans.
Abortion: Abortion is not one of the essential health benefits. States have the right to ban abortion coverage in health plans sold on the state Marketplace and more than half the states have done so. Check with your individual plan to see whether it is covered.
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Cosmetic surgery
Dental care (Adult)
Infertility treatment
Long-term care
Non-emergency care when traveling outside the U.S.
Private-duty nursing
Routine eye care (Adult)
Routine foot care
Are the benefits the same in each state?
Generally, yes. But some states require insurers to cover additional services and procedures. Even within the same state, there can be small differences.
When you compare plans in the Marketplace, you’ll see the specific benefits each plan offers.
What if I need a specific treatment that’s not on this list?
Plans may cover other services. When you compare plans, you’ll see more detailed information about what’s covered. If you want to find out if a particular service is covered, call the plan.
Do all types of Marketplace plans cover essential health benefits?
Yes. Any plan shown in the Marketplace includes these essential health benefits. This is true for all plan categories (all “metal levels,” including Catastrophic plans) and all plan types (like HMO and PPO).
Do I have to pay deductibles and copayments for essential health benefits?
Generally, yes. All Marketplace plans have
,
, and other
that apply to most covered services.
Some
Do I get these benefits if my company is self-insured?
It depends. Large employers who “self-insure” — meaning they pay employees’ health care costs directly — don’t have to provide essential health benefits. But many do. Check with your employer to find out if it’s self-insured and what services are covered.
Are abortion services covered by Marketplace plans?
Sometimes, and plans may have different restrictions. Some offer no coverage or coverage with restrictions. In some cases abortion services cannot be paid for with federal dollars (these are known as “non-Hyde” abortion services).
Contact each plan to learn about its abortion coverage.
