Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on your state’s requirements. Plans may offer additional benefits, including:
Vision coverageA health benefit that at least partially covers vision care, like eye exams and glasses. All plans in the Health Insurance Marketplace® include vision coverage for children. Only some plans include vision coverage for adults. Refer to glossary for more details.
When comparing plans, you’ll see exactly what each plan offers.Generally, yes. But some states require insurers to cover additional services and procedures. Even within the same state, there can be small differences.
When you compare plans in the Marketplace, you'll see the specific benefits each plan offers.Plans may cover other services. When you compare plans, you’ll see more detailed information about what’s covered. If you want to find out if a particular service is covered, call the plan.
Yes. Any plan shown in the Marketplace includes these essential health benefits. This is true for all plan categories (all “metal levels,” including Catastrophic plans) and all plan types (like HMO and PPO).
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Refer to glossary for more details.
copaymentsA fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Refer to glossary for more details.
out-of-pocket costsYour expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
Refer to glossary for more details.
that apply to most covered services. preventive servicesRoutine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Refer to glossary for more details.
are free, and some plans cover other services without out-of-pocket costs.It depends. Large employers who "self-insure” — meaning they pay employees' health care costs directly — don't have to provide essential health benefits. But many do. Check with your employer to find out if it’s self-insured and what services are covered.
Sometimes, and plans may have different restrictions. Some offer no coverage or coverage with restrictions. In some cases abortion services cannot be paid for with federal dollars (these are known as “non-Hyde” abortion services).
Contact each plan to learn about its abortion coverage.An individual health insurance policy purchased on or before March 23, 2010. These plans weren’t sold through the Marketplace, but by insurance companies, agents, or brokers. They may not include some rights and protections provided under the Affordable Care Act.
Refer to glossary for more details.
cover essential health benefits, but they’re not required to. To be sure, check with your employer or health plan.