While the Affordable Care Act greatly expanded Americans’ access to health insurance, there are still many things Obamacare plans won’t cover. All plans offered through the government’s health insurance marketplace are required to to accept individuals with preexisting health conditions and to offer a set of essential health benefits. These include emergency services, hospitalizations, pregnancy care and behavioral health treatment, among other things.
But certain services that might seem essential to you may not be considered essential by law or by your insurance company. Why? “These plans were designed by Congress,” explains David Reid, CEO of EaseCentral, an HR benefits software company, and 30-plus year health-industry veteran and benefits expert. The Affordable Care Act determined the essential health benefits list – what insurers had to cover – so that plans would be consistent across carriers and consumers would know they were comparing apples to apples, and not be deceived by the fine print when shopping around. Unfortunately, as so often happens, the minimum became the maximum: If the ACA didn't specify a service had to be included, the insurer's marketplace plan often wouldn't offer it. "The objective is good, but the result isn't what everyone expected,” he says.
So, the availability of certain services varies by state and by health insurance plan. Here's a list of items that could well not be included.
Things Obamacare Plans Won’t Cover
1. Adult Dental Care
Dental coverage is an essential health benefit for children 18 and younger, but is often not covered for adults. Some marketplace plans do include dental insurance for adults. Another option adults have is to purchase a separate dental insurance plan through the marketplace, but you must buy it at the same time as you buy your health insurance plan.
You can estimate the cost of various dental procedures in your area using FAIR Health Dental Cost Lookup Tool. For example, if you live in Manhattan, you might pay $179 for a comprehensive dental exam, $200 for a simple dental cleaning and $395 for a white (composite) two-surface filling on a back tooth. For more, see Should You Bite on Dental Insurance?
2. Adult Eye Care
Like dental coverage, the Affordable Care Act requires vision coverage only for children. Some marketplace plans cover vision care for adults; others don’t. Unlike dental insurance, you can’t buy an adult vision plan through the government’s health insurance marketplace. Instead, you’ll have to buy it through an insurance agent or broker or directly from an insurance company.
3. Long-Term Care
Although the need for long-term care services arises from illnesses and accidents, whose treatments are generally covered by health insurance, long-term care itself – the assistance you might need with activities of daily living such as bathing, eating and dressing if you become severely ill or disabled – is not usually covered by ACA health insurance plans. (It isn't covered by Medicare, either, but that's another story.)
To gain this coverage, you must purchase a long-term care insurance policy or a life insurance policy with a long-term care rider. According to Genworth’s 2016 Cost of Care Survey, the national median cost for one month of nursing-home care in a semi-private room is $6,844 (a private room costs $7,698). For in-home care from a home health aid, the national median monthly cost is $3,861. (See Your Complete Guide to Long-Term Care Insurance and Pros and Cons of Smaller Long-Term Care Facilities.)
Twenty-five states either don’t allow marketplace health insurance plans to cover abortion or severely restrict coverage to cases of rape, incest or endangerment of the woman’s life, according to a January study by the Kaiser Family Foundation. Six more states have no abortion coverage, even though state law doesn’t prohibit insurers from covering it.
Only in Hawaii and Vermont do all marketplace plans cover termination of pregnancy. An abortion can cost anywhere from $400 to $1,650 depending on the state, the facility and how far along the pregnancy is.
5. Infertility Treatments
Only 15 states require health insurance plans to cover infertility treatment, according to Resolve, a national non-profit devoted to research and resources for dealing with infertility. Even in those states, an insurance plan may not cover infertility treatment if it is a self-insured employer plan or if the plan does not cover a minimum number of employees, such as 25 or 50.
Further, each state has different definitions of infertility. In California, a woman can be considered infertile after failing to get pregnant for a year, but in Arkansas, the threshold is two years (unless the woman has one of a few named conditions, such as endometriosis). Which infertility treatments may be covered also vary by state. For example, some states do not require coverage for in-vitro fertilization.
Tests to diagnose infertility typically cost a few hundred dollars each; fertility drugs can cost a few hundred to several thousand dollars. In-vitro fertilization (IVF) typically costs $10,000 or more.
6. Weight-Loss Programs and Surgeries
In 24 states, health insurance plans are not required to cover bariatric or gastric bypass surgery, procedures that restrict the amount of food the stomach can hold to limit how much patients can eat and how many calories their bodies can absorb. Weight-loss surgery can cost about $15,000 to $23,000, depending on the procedure. In 27 states, there is no requirement to cover nutritional counseling or therapy for obese patients, according to the National Conference of State Legislatures. However, all 50 states require marketplace plans to cover obesity screening and counseling with no out-of-pocket costs to patients.
The Bottom Line
“Why don’t these plans cover more? It likely boils down to economics,” says Michael Levin, co-founder and CEO of Vericred, a data provider for the health insurance industry. "Market competition effectively caps premiums." If insurance companies offered more benefits, claims would go up. Premiums would need to go up as a result. That would make plans that offered more benefits less competitive or not competitive at all, he says.
If you need health services like the ones listed above, you may have to pay the full cost out-of-pocket, depending on where you live and which insurance plan you have. If that’s the case, look for ways to reduce your costs, such as shopping around and asking for a cash discount.