What plans cover

What Marketplace health plans cover

All private health insurance plans offered in the Marketplace offer the same set of essential health benefits. These are services all plans must cover.

The essential health benefits include at least the following items and services:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as surgery)
  • Pregnancy, maternity, and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

Note: All Marketplace plans must offer pediatric dental and vision care for children 18 and under. But this isn’t true for adults. You’re not required to have them, but be sure to shop around if you want them.

Additional benefits

Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.

Additional benefits information:

More answers on Marketplace coverage

Do I get these benefits if I have a grandfathered plan?

Not necessarily. Many grandfathered plans cover the essential health benefits. But grandfathered plans aren't required to offer them. Check with your employer or health plan to find out if your plan is grandfathered and learn what benefits it offers.

Learn more about your rights and benefits under a grandfathered health plan.
Are the benefits the same in each state?

Generally, yes. But while all Marketplace plans offer the same general set of essential health benefits, specific benefits may be different in each state. Some states require insurers to cover certain services and procedures. Even within the same state, there can be small differences between plans.

When you fill out your Marketplace application and compare plans, you'll see the specific benefits each plan offers. Read the plan details carefully before you enroll.
What if a specific treatment I need isn’t on this list?

Plans cover many individual services within the broad categories on the list of essential benefits. When you compare plans in the Marketplace, you’ll be able to see more detailed information about covered benefits.

Do all categories of plans – Bronze, Silver, Gold, and Platinum – cover essential health benefits?

Yes. No matter what category of Marketplace plan you choose, essential health benefits are covered. This applies to catastrophic plans too. Learn more about the different categories of plans.

Do all types of plans available on the Marketplace – like PPOs, HMOs, and high-deductible plans – cover essential health benefits?

Yes. All plans available on the Marketplace must cover the essential health benefits. Learn more about different types of health plans.

Will I have to pay deductibles and copayments for essential health benefits?

Generally, yes. All plans in the Marketplace will have deductibles, copayments, and other out-of-pocket costs that apply to most benefits. These costs differ in part based on what category of plan you choose.

Some preventive care services are free, and some plans may provide certain other services without out-of-pocket costs.
Do I get these benefits if my company is self-insured?

Not necessarily. Many large employers "self-insure." This means they pay the costs of employees' health care directly. Many of them cover the essential health benefits. But companies that self-insure don't have to provide this package of benefits. Check with your employer to find out if it is self-insured and learn about your covered benefits.