In the United States, life healthcare requirements—often referred to as essential health benefits—are a set of minimum coverage standards that health insurance plans must meet under the Affordable Care Act (ACA). These standards ensure comprehensive, basic health services are available to all individuals and small group insurance holders, both on and off the Health Insurance Marketplace[1].
The ten essential health benefit categories mandated by the ACA include:
- Ambulatory patient services (outpatient care without being admitted to a hospital)[3].
- Emergency services[3].
- Hospitalization (such as surgery and overnight stays)[3].
- Maternity and newborn care[3].
- Mental health and substance use disorder services, including behavioral health treatment[3].
- Prescription drugs[3].
- Rehabilitative and habilitative services and devices (help patients acquire, maintain, or improve necessary physical and mental skills)[3].
- Laboratory services[3].
- Preventive and wellness services and chronic disease management[3].
- Pediatric services, including oral and vision care[3].
Insurance plans must provide these benefits with limits on annual out-of-pocket costs and are prohibited from placing annual or lifetime caps on the total cost of covered services[1]. However, limits on the number of specific covered visits (such as therapy sessions) are allowed[1].
Plans that meet these standards are considered to offer minimum essential coverage, which also includes employer-sponsored plans, Medicare, most Medicaid plans, and the Children’s Health Insurance Program (CHIP). While minimum essential coverage is no longer required by federal mandate, some states still require residents to maintain this level of insurance[6].
Coverage specifics, such as which preventive services are free versus subject to cost-sharing, may vary based on individual state laws and plan details. It’s important for consumers to review the Summary of Benefits and Coverage provided by their insurer to understand what is included in their plan[5].
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