Essential Health Benefits
Plain English
Essential health benefits are the 10 kinds of care all Marketplace health plans must cover, including emergency care, hospital stays, pregnancy and childbirth, mental health care, prescriptions, lab tests, preventive care and children's dental and vision. They're a minimum: exact services vary by state, and plans can add more, like adult dental.
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Definition
Essential health benefits are 10 categories of services that all Marketplace health plans must cover: outpatient care, emergency services, hospitalization, pregnancy and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, lab services, preventive and wellness care and chronic disease management, and pediatric services including children's dental and vision.
Why It Matters
They set the floor for what a Marketplace plan includes, so you can compare plans on cost and network knowing core care is there. They also explain gaps: adult dental and vision aren't essential health benefits, so they're often separate.
Real-World Example
Imagine someone comparing two Bronze plans assumes the cheaper one leaves out mental health care. Both must cover mental health and substance use disorder services as essential health benefits. The real differences are the deductible, the network and which specific drugs are on each plan's list.
Common Misconceptions
- Essential health benefits include adult dental and vision. They don't; pediatric dental and vision are included.
- All plans include the exact same services. The categories are the same, but specific services vary by state.
- Short-term plans must include them. The rules apply to Marketplace plans.
Key Takeaways
- HealthCare.gov: all Marketplace plans cover these 10 essential health benefits.
- They include mental health and substance use disorder services, and prescription drugs.
- Adult dental and vision coverage aren't essential health benefits.
- Specific covered services within each category can vary by state.
Frequently Asked Questions
What are the 10 essential health benefits?
Outpatient care, emergency services, hospitalization, pregnancy and newborn care, mental health and substance use services, prescription drugs, rehabilitative services, lab services, preventive care and chronic disease management, and pediatric services.
Is dental an essential health benefit?
Children's dental is. Adult dental isn't, so it's often bought separately.
Do all health plans include essential health benefits?
All Marketplace plans must. Some other plan types, like some short-term plans, don't have to.
Related Terms
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- Health Insurance
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Explore the rest of the Health Insurance category.
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The factual claims on this page were checked against these sources. Rules and figures change, so check the source itself if you need to confirm the current version.
- healthcare.govWhat Marketplace health insurance plans cover · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
Educational information, not advice: This page is for general education only, not legal, financial, or insurance advice. Actual coverage, discounts, and requirements depend on your policy’s wording, your insurer, and the laws of your state. Confirm specifics with your own insurer or a licensed agent before making a decision. Insurpedia does not sell insurance and does not recommend specific insurers.