A Comprehensive Guide to ACA Essential Health Benefits

Importance of ACA Essential Health Benefits

The ACA was enacted to address numerous issues within the healthcare system, including the lack of coverage for critical health services in many insurance plans. Before the ACA, many insurance enrollees found themselves without coverage for vital services when they needed them the most. This often led to financial stress and, in some cases, a reluctance to seek necessary medical care.

By establishing the ACA Essential Health Benefits, the law ensures that all Americans have access to comprehensive health insurance coverage. These standards apply to plans sold on the individual and small-group markets, as well as to certain Medicaid programs.

Overview of ACA Essential Health Benefits

“The ACA mandates that certain health insurance plans cover a minimum standard of benefits.”

These are known as the ACA Essential Health Benefits and encompass 10 categories of health services. Here is a summary of these 10 essential health benefits:

• Ambulatory Patient Services: This category covers outpatient services, including doctor's visits and same-day surgeries. Without this coverage, individuals may delay seeking medical care, potentially leading to more severe health issues.
• Emergency Services: Coverage for emergency services includes emergency room visits and emergency transportation. Given that a single emergency room visit can cost thousands of dollars, this coverage is crucial for financial protection.
• Hospitalization: This benefit covers stays in a hospital, including surgeries. Hospitalization coverage is vital for financial security as even a short stay in a hospital can cost tens of thousands of dollars.
• Maternity and Newborn Care: This coverage includes care during pregnancy, childbirth, and postnatal care. Prior to the ACA, many plans did not cover these services or charged exorbitant premiums for them.
• Mental Health and Substance Use Disorder Services: This category includes coverage for services like counseling and psychotherapy. Before the ACA, a large number of plans did not have mental health coverage.
• Prescription Drugs: All ACA-compliant plans must cover at least one drug in every category and class of prescription medications. This requirement ensures that individuals can access the medications they need.
• Rehabilitative and Habilitative Services and Devices: These services help individuals recover or develop skills necessary for daily living. Coverage for these services is crucial for individuals to live full, independent lives.
• Laboratory Services: This category includes laboratory tests used by doctors to diagnose and monitor health conditions.
• Preventive and Wellness Services and Chronic Disease Management: This benefit includes coverage for routine preventive care, such as vaccinations and management of chronic diseases.
• Pediatric Services, Including Oral and Vision Care: This requirement ensures that children receive comprehensive care, including dental and vision services.

Understanding State-specific EHB-Benchmark Plans

While the ACA sets federal standards for the ACA Essential Health Benefits, the exact coverage details can vary based on the state-specific EHB-benchmark plans. These benchmark plans serve as a reference for the minimum level of services that health insurance plans within a state must offer.

Starting from the plan year 2020, the Centers for Medicare and Medicaid Services (CMS) have granted states greater flexibility in updating their EHB-benchmark plans. States can choose from three options: they can select a benchmark plan used by another state in the 2017 plan year, replace categories of EHBs from their 2017 benchmark plan with those from another state's 2017 plan, or select a new set of benefits to form their benchmark plan.

Several states have taken advantage of this flexibility to update their EHB-benchmark plans. For instance, in the 2020 plan year, CMS approved changes to the Illinois EHB-benchmark plan, and in the following years, changes to the benchmark plans of South Dakota, Michigan, New Mexico, Oregon, Colorado, and Vermont were approved as well.

Implications of Not Having Minimum Essential Coverage

While the federal penalty for not having minimum essential coverage was eliminated in 2019, some states, including California, Massachusetts, New Jersey, Rhode Island, and Washington, D.C., still require residents to maintain minimum essential coverage. Failure to comply can result in a state-level penalty.

Additionally, not having minimum essential coverage could mean that your health insurance plan does not provide comprehensive coverage. This could leave you vulnerable to high out-of-pocket costs if you require certain health services.

How to Determine and Obtain Minimum Essential Coverage

To ensure you have minimum essential coverage, you should carefully review the details of your health insurance plan. Plans offered by employers and government programs generally meet the requirements for minimum essential coverage. However, plans that only provide specific benefits, such as dental or vision coverage, or discount plans, do not qualify as minimum essential coverage.

If you need to secure minimum essential coverage, you can do so by purchasing a plan from the marketplace or obtaining insurance through your employer. Online resources such as eHealth can provide assistance in comparing and choosing plans that meet your needs and comply with the ACA's requirements for minimum essential coverage.

Wrapping Up

In conclusion, the ACA Essential Health Benefits are a crucial part of the ACA's impact on healthcare in the United States. By mandating that certain health insurance plans cover a minimum standard of benefits, the ACA ensures that all Americans have access to comprehensive health insurance coverage. Understanding these essential benefits can help you make informed decisions about your health insurance coverage and ensure that you have the protection you need.