Under the Affordable Care Act (ACA), all qualified health plans offered on the federal exchange or private individual market must cover ten comprehensive categories of services with zero pre-existing condition exclusions.
What Are the 10 Essential Health Benefits?
By federal mandate, no insurance carrier can omit or cap lifetime benefits on any of the following healthcare pillars:
- Ambulatory Patient Services: Outpatient medical care you receive without being admitted to a hospital facility.
- Emergency Services: Emergency room treatment covered at in-network rates nationwide without prior authorization.
- Hospitalization: Inpatient hospital stays, surgeries, overnight physician monitoring, and nursing care.
- Pregnancy, Maternity, and Newborn Care: Complete prenatal checkups, labor, delivery, and newborn pediatric care.
- Mental Health and Substance Use Disorder Services: Outpatient behavioral therapy, psychotherapy, and inpatient substance rehabilitation.
- Prescription Drugs: Mandatory coverage of medications across therapeutic classes listed in the carrier formulary.
- Rehabilitative and Habilitative Services: Physical therapy, occupational therapy, and speech recovery devices.
- Laboratory Services: Diagnostic blood panels, pathology, urine testing, and imaging scans.
- Preventive and Wellness Services: Annual physical exams, mammograms, colonoscopies, and immunizations at $0 copay.
- Pediatric Services: Comprehensive pediatric healthcare, including mandatory pediatric dental and vision exams until age 19.
At Prime Health Global, our licensed brokers ensure your plan covers every essential benefit while securing maximum federal tax credits.
