What does Marketplace health insurance cover?
All private health insurance plans offered in the Marketplace will 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)
- 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
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.
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More Answers: Essential Health Benefits
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 do not 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.
Do I get these benefits if I have a grandfathered plan?
Not necessarily. Many grandfathered plans cover the essential health benefits. But grandfathered plans are not 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.
Can insurance plans offer additional benefits?
Yes. You'll find out what benefits each insurance plan covers when you compare plans in the Marketplace.
Are the benefits the same in each state?
Generally, yes. But while all Marketplace plans offer the same general set of benefits, specific benefits may be different in each state. 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.
What if a specific treatment I need isn’t on this list?
Plans will cover many individual services within the broad categories on this list. When you compare plans in the Marketplace, you will be able to see more detailed information about covered benefits under these categories. In addition, states may require plans to cover other benefits. Health plans may also choose to cover additional benefits.
Do all categories of plans – bronze, silver, gold, and platinum – cover essential health benefits?
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?
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.
Is dental coverage an essential health benefit?
Dental services for children under 18 are an essential health benefit. You may be able to get these benefits from a Marketplace plan or a free-standing child or family dental plan you buy separately in the Marketplace.
Dental coverage is not an essential health benefit for adults. But dental policies for adults and families are available in the Marketplace. Learn more about dental coverage.
Is treatment for pre-existing conditions covered?
Yes. Essential health benefits for pre-existing conditions are covered under all Marketplace plans. No insurer can reject you, charge you more, or refuse to pay for essential health benefits for a pre-existing condition. Learn more about coverage for pre-existing conditions.
What plans should I consider if I travel a lot or spend time in more than one state?
If you live in one state and work or spend a lot of time in another state, carefully check the provider directories of the plans you’re thinking about buying.
See if their networks have doctors, hospitals, and other health care providers in the places you’ll be. Also check out the plan’s payment policies for out-of-network care.
- Some plans have networks that cover only part of one state. Other plans have networks that cover much of the country.
- If you use a doctor or facility that’s not in your plan’s network, you may have to pay more for the services you get.
Marketplace plans must have a link to a provider network directory on their website – and the directory must have the most current listing of in-network providers. You can also contact the plan to confirm your doctor or facility is part of the network.
HealthCare.gov provides direct links to provider directories for all Marketplace plans, so you can easily tell what your plan covers.