Essential Health Benefits

DEFINITION of 'Essential Health Benefits'

A set of benefit requirements that must be included in certain health insurance plans. Essential health benefits comprise 10 general benefit categories, which must be covered in health insurance plans offered to individuals or through the small-group market to employers with 50 or fewer employees, under the Patient Protection and Affordable Care Act (ACA), the U.S. health reform law signed into law by President Obama in March 2010.

BREAKING DOWN 'Essential Health Benefits'

A health-care expense is “covered” if your plan benefits are applied to the item or service. For example, if chiropractic care is a covered benefit on a certain policy, plan benefits – such as a $25 copayment – would apply to chiropractic visits. In contrast, if chiropractic care is not a covered benefit, any expenses incurred through chiropractic visits would have to be paid entirely out-of-pocket, and the expenses would not count toward the policy’s deductible or out-of-pocket limit. While plans can offer more comprehensive benefits, essential health benefits constitute the minimum benefits for plans offered to individuals and through the small-group market to employers with 50 or fewer employees. The essential health benefits are:

  •  Ambulatory patient services – Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center.
  •  Emergency services – Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness.
  •  Hospitalization Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board.
  •  Laboratory services – Testing provided to help a doctor diagnose an injury, illness or condition, and to monitor the effectiveness of a particular treatment.
  •  Maternity and newborn care – Care that women receive during pregnancy (prenatal care), throughout labor and delivery, and post-delivery; and care for newborn babies.
  •  Mental health services and addiction treatment – Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder.
  •  Rehabilitative services and devices – Rehabilitative and habilitative services and devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition.
  • Pediatric services Care provided to infants and children, including well-child visits and recommended vaccines and immunizations, dental and vision care.
  •  Prescription drugs – Medications prescribed by a doctor to treat an illness or condition.
  •  Preventive and wellness services and chronic disease treatment – Physicals, immunizations and cancer screenings designed to prevent or detect certain medical conditions, and care for chronic conditions.
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