ObamaCare’s Essential Benefits vs. Covered Benefits
Under the ACA all major medical plans must offer at least one covered service from ten categories of essential health benefits. That makes all essential benefits covered benefits on every plan. Aside from these, an insurer can include other covered benefits.
Starting January 1st of 2014, the following “Ten Essential Benefits” must be included under all insurance plans with no lifetime or annual dollar limits:
- Emergency services
- Laboratory services
- Maternity care
- Mental health and substance abuse treatment
- Outpatient, or ambulatory care
- Pediatric care
- Prescription drugs
- Preventive care
- Rehabilitative and rehabilitative (helping maintain daily functioning) services
- Vision and dental care for children
Other common covered benefits examples are:
- Abortion services of which Federal funds are prohibited
- Hearing aids (Coverage for cochlear implants only)
- Routine foot care (For diabetes treatment)
- Chiropractic care
What Services are Not Considered Covered Benefits?
There is no hard-and-fast rule of what your plan will or will not cover. Here are some examples of typical uncovered benefits.
- Bariatric surgery
- Infertility treatment
- Private-duty nursing
- Cosmetic surgery
- Long-term care
- Routine eye care (Adult)
- Dental care
- Non-emergency care when traveling outside the U. S.
- Weight loss programs
Benefit Allowed Amounts?
A benefit can be covered up to an allowed amount. This means your coinsurance will pay up to X amount after your deductible. Go over, and that is called balance billing. That means you are stuck with the bill and it doesn’t go toward your maximum.
There is also limits to the amount of times you can access a service at a cost sharing level.
How do Networks Work With Benefits?
If you have a referral (if needed) you can use an in-network service at the full cost sharing amount. Go out-of-network, and depending on your plan, will owe a greater amount or the full amount of the service. Covered benefits, how they are covered, and the network they are covered under go hand-and-hand.