Upon request, the Affordable Care Act (ACA) requires every health insurance company to give you a Summary of Benefits and Coverage. This document explains your benefits and coverage limits in easy-to-understand language.
Benefits that health plans must cover under the federal ACA
Under the ACA, the following 10 essential health benefits apply to individual/family and small employer health plans.
| Health benefit | Description |
|---|---|
| Ambulatory patient services | Covers outpatient care without being admitted to a hospital. |
| Emergency medical services in an emergency department | Covers services provided in an emergency department if a medical provider believes the patient is having an emergency. |
| Hospitalization | Surgery and overnight stays. |
| Maternity and newborn care | Coverage for maternity and newborn health care. |
| Mental health substance abuse disorder services | Behavioral treatment, mental and behavioral health inpatient services, and substance abuse disorder treatment. |
| Lab services | Diagnostic testing, such as blood draws or urinalysis ordered by a medical provider. |
| Pediatric services | Health care for children from birth to age 19, including dental and vision care. |
| Prescription drugs | Medications prescribed by a medical provider that patients buy through a pharmacy. |
| Preventive and wellness services and chronic disease management | Preventive services, such as shots and screening tests, at no cost to the patient when a medical provider from the plan's network delivers the service. |
| Rehabilitative and habilitative services and devices | Services and devices to gain or recover mental and physical skills for people with injuries, disabilities, or chronic conditions. |
Benefits health plans must cover under Washington state law
In addition to the health benefits covered under the ACA, certain individual/family and group health plans must also offer specific health benefits according to Washington state law.