For Consumers

What health insurance plans must cover

The Affordable Care Act (ACA) requires every health insurance company, upon your request, to give you a Summary of Benefits and Coverage (www.healthcare.gov) that explains your benefits and coverage limits in easy-to-understand language.

Although some health plans offer additional benefits, state and federal laws require plans to provide the following services:

Note: Most health plans are not allowed to have annual benefit limits, and no plans are allowed to have lifetime benefit limits.

Preventive services

Under the ACA, most health plans must cover preventive services (www.healthcare.gov) with no out-of-pocket costs to you. This means you won't have a copay or coinsurance for certain medical services, such as immunizations or blood pressure screenings, as long as they're delivered by a medical provider in your plan's network.

Benefits health plans must cover under the federal ACA

Under the ACA, the following 10 essential health benefits (www.healthcare.gov) apply to individual/family and small employer health plans:

  1. Ambulatory patient services: Covers outpatient care without being admitted to a hospital
  2. 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
  3. Hospitalization: Surgery and overnight stays
  4. Maternity and newborn care: Coverage for maternity and newborn health care
  5. Mental health substance abuse disorder services: Behavioral treatment, mental and behavioral health inpatient services and substance abuse disorder treatment
  6. Lab services: Lab services, such as blood draws or urinalysis, a medical provider orders
  7. Pediatric services: Health care for children from birth to age 19, including dental and vision care
  8. Prescription drugs: Medications a medical provider prescribes that patients buy through a pharmacy
  9. 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
  10. 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