How Do I Find Out What’s Covered in a Health Plan?

The Affordable Care Act (ACA) requires individual and small group1 plans to offer certain health benefits, known as Essential Health Benefits. In addition to the Essential Health Benefits, each plan may cover a range of other benefits, though the services and coverages may differ based on the plan and the health insurer.

Essential Health Benefits

The Essential Health Benefits include the following services:

  • Preventive, wellness, and disease management services
  • Emergency care
  • Ambulatory services
  • Hospitalization
  • Maternity and newborn services
  • Pediatric services, including dental and vision
  • Prescription drugs
  • Laboratory services
  • Mental health and substance abuse services, including behavioral health treatment
  • Rehabilitation and habilitation services

Other health plan benefits

When choosing a health plan, you will typically receive an overview of what benefits the plan covers and how much of the costs are shared by the health insurer. You may also ask them to provide a Summary of Benefits and Coverage for more information. If you have questions about an individual health plan you’re purchasing directly from a health insurer, you should contact their Customer Service department. If you have questions about an employer health plan, contact your HR or benefits representative.

Ten Questions to Ask Before Choosing a Health Plan

1 Small groups are those with 100 or fewer employees.