For Consumers

What are the required health benefits?

Upon request, the Affordable Care Act (ACA) requires every health insurance company to give you a Summary of Benefits and Coverage (www.healthcare.gov) that explains your benefits and coverage limits in clear, easy-to-understand language. Although some health plans offer additional benefits, plans are required by state and federal laws to provide certain benefits:

Benefits that all plans must cover

Preventive services without cost-sharing (www.healthcare.gov) - For your health plan to provide you with preventive benefits, your in-network medical provider will need to bill your treatment as a preventive service.

Ten essential health benefits under the ACA (leg.wa.gov):

Note: Essential health benefits apply only to individual and family/small-group plans.

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and treatment of substance abuse disorders, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services, including chronic disease management
  10. Pediatric services, including oral and vision care