What does the health plan cover?


Visual summary of essential health benefit categories


The Affordable Care Act ensures that health plans offer a broad package of items and services known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories if the plan is offered on the Federally Facilitated Health Insurance Marketplace:

  • Ambulatory patient services, such as care provided at a clinic or same-day surgery center
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services including chronic disease management
  • Pediatric services, including oral and vision care

Insurance policies must cover these benefits in order to certified and offered through the Health Insurance Marketplace.  Once you enroll in a health insurance plan, you will be given a certificate of coverage. It may also be called a contract, evidence of coverage, or summary plan description (SPD). You can call your insurance customer service department at any point during your coverage and ask for a written copy of your certificate of coverage. This should be provided free of charge.  

This document explains the health benefits you and your dependents have under the plan. It details the services that will and will not be covered.  Certificates usually have a section of definitions to explain words that have special meanings. To fully understand your coverage, it is wise to read the definitions section.