ACA Spotlight: What Are Essential Health Benefits?

///ACA Spotlight: What Are Essential Health Benefits?

Are you wondering what your health insurance must cover under Obamacare?  Under the Affordable Care Act (ACA), non-granfathered health plans offered in the individual and small group markets, both inside and outside of the Exchanges must offer a package of items and services.  These services are known as Essential Health Benefits (EHB.)  There are ten categories that must be included in EHBs.

Even though EHBs mean that insurance must cover these areas, it does not guarantee a cost or percentage that will be paid by the carrier.  In addition, carriers may offer coverage for additional benefits and services.  One of the most important things to remember about EHBs is that it sets the bar for minimum coverage for a plan under ACA.

Each state is permitted to benchmark EHBs into a state benchmark plan.  Below is the EHB Benchmark Plan for Ohio.

Ambulatory Patient Services

  • Primary care visits to treat an injury or illness
  • Physician office visits and treatment, including nurse and physician assistant services
  • Specialist visits
  • Outpatient facility fees
  • Outpatient surgery
  • Outpatient physician and professional services
  • Outpatient medical and surgical supplies
  • Urgent care centers or facilities
  • Allergy treatment
  • Outpatient Chemotherapy
  • Outpatient radiation therapy
  • Home health care services
  • Hospice services
  • Renal Dialysis/Hemodialysis

 

Emergency Services

  • Emergency room services
  • Emergency transportation
  • Emergency care outside the U.S.

 

Hospitalization

  • Inpatient hospital services
  • Inpatient physician services
  • Inpatient surgical physician and professional services
  • Skilled nursing facilities

 

Maternity and Newborn Care

  • Delivery and all inpatient services for maternity and newborn care
  • Prenatal care
  • Postnatal care

 

Mental Health and Substance Use Disorder Services

  • Mental/Behavioral health outpatient services
  • Mental/Behavioral health inpatient services
  • Partial day mental health services
  • Substance abuse disorder outpatient services
  • Substance abuse disorder inpatient services
  • Partial day substance abuse services
  • Intensive outpatient programs

 

Prescription Drugs

  • Generic drugs
  • Non-formulary drugs
  • Formulary brand-name drugs

 

Rehabilitative and Habilitative Services and Devices

  • Inpatient physical rehabilitation services including cardiac, pulmonary, speech and occupational therapy
  • Outpatient physical rehabilitation services including cardiac, pulmonary, speech and occupational therapy
  • Chiropractic care
  • Durable medical equipment
  • Habilitative services including the following services for children diagnosed with Autism Spectrum Disorder:
  •      -Speech and language therapy and/or occupational therapy
  •      – Clinical therapeutic intervention
  •      – Mental/behavioral health outpatient services

 

Laboratory Services

  • Diagnostic X-ray and lab work
  • Imaging (CT and PET scans, MRIs)

 

Preventative Wellness Services and Chronic Disease Management

Preventative services for adults including, but not limited to

  • Alcohol misuse screening and counseling
  • Aspirin use
  • Blood pressure screening
  • Cholesterol screening
  • Colorectal screening
  • Depression screening
  • Type 2 diabetes screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • Obesity screening and counseling
  • HIV screening
  • Sexually transmitted infection prevention screening and counseling for adults at higher risk

 

Preventative services for women including, but not limited to

  • Cervical cancer screenings
  • Mammography screenings
  • Well-woman visits
  • Gestational diabetes screening
  • Human Papilomavirus (HPV) testing
  • Counseling for sexually transmitted infections
  • Counseling and screening for human immune-deficiency virus
  • Contraceptives methods and counseling
  • Breastfeeding support, supplies, and counseling
  • Screening and counseling for interpersonal and domestic violence
  • Osteoporosis screening

 

Preventative services for children including, but not limited to

  • Medical History
  • Depression and alcohol and drug use assessments for adolescents,
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments
  • Height, weight and body mass index (BMI) measurements
  • Blood pressure screening
  • Developmental screening and surveillance
  • Hearing screening for newborns
  • Oral health risk assessment
  • Vision screening
  • Obesity screening and counseling

 

Adult, adolescent, and child immunization vaccines

Routine hearing screenings for adults

Routine vision screenings for adults

Tobacco cessation counseling

 

Pediatric Services, Including Oral and Vision Care

  • Basic dental services and supplies
  • Intermediate dental services and supplies
  • Major dental services and supplies
  • Orthodontic services and supplies
  • Diagnostic eye exams
  • Prescription eyeglasses or contact lenses

Remember that this list is how Ohio defines Essential Health Benefits and that other benefits and services may be covered by an insurance carrier.  If you have questions about Essential Health Benefits, contact usat AUI.

Thank you,

Chris Johnston

2019-03-07T20:31:25-05:00