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What Your ACA Health Plan Covers

by | Dec 21, 2021 | ACA Enrollment, Affordable Care Act (ACA), Enrollment, Healthcare

If you are new to the Affordable Care Act (ACA) marketplace or if you just need a refresher, here is a list of the healthcare services that your plan must cover.

If you haven’t signed up yet, you have until January 15, 2022. Your health coverage would start February 1.

10 Essential Health Benefits

All ACA health plans cover 10 essential health benefits:

  1. Ambulatory services: care you get from doctors or providers in their office or clinic 
  2. Emergency services: life or limb-threatening health issues that require immediate care 
  3. Hospitalization: care you get when you stay at least one night in a hospital
  4. Pregnancy, maternity, and newborn care before and after you give birth 
  5. Mental health and substance use disorder services, including behavioral health treatment, counseling, and psychotherapy
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices: care for injuries, disabilities, or chronic conditions to help you gain or recover mental and physical skills
  8. Lab services like blood work
  9. Preventive, wellness, and chronic disease management services
  10. Pediatric services: oral and vision care for children

Adult Dental and Vision Coverage

Dental and vision coverage are not considered essential health benefits for adults. Some plans do cover vision and dental care, so check your plan. 

If your plan doesn’t cover dental or vision care, you can buy separate dental or vision plans through the marketplace. If you buy one or both of these plans, you will pay separate monthly premiums, deductibles, and copays for each plan. Each plan will also have its own limit on out-of-pocket costs.

If You Have a Pre-existing Medical Condition

All ACA marketplace plans must cover treatment for pre-existing medical conditions:

  • No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any conditions you had before your coverage started.
  • Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.
  • If you’re pregnant, coverage starts the day your plan starts.

Exception: grandfathered plans don’t have to cover pre-existing conditions

If you have been enrolled in the same plan since before March 23, 2010, you could be in a grandfathered plan that doesn’t have to cover pre-existing conditions or preventive care. 
If you think you have a grandfathered plan, you can switch to a marketplace plan. Now is the time to switch. You have until January 15, when open enrollment ends.

Pregnancy Care

If you’re pregnant when you apply, your plan can’t reject you or charge you more because of your pregnancy. Pregnancy and childbirth coverage begins the day your plan starts. 

Your plan must also provide breastfeeding support, counseling, and equipment for as long as you breastfeed your child. These services may be provided before and after birth.

Birth Control

Contraception methods and counseling are covered for women when prescribed by a doctor. You can’t be charged a copay or coinsurance when you get the services from an in-network provider, even if you haven’t met your deductible.

Preventive Health Services

Your ACA health plan must cover services to find and prevent diseases and health problems before they get worse. These services include shots and screening tests. 

Visit healthcare.gov to get see what’s covered for: 

Mental Health and Substance Abuse

Your marketplace plan also covers mental health and substance abuse services, including: 

  • Behavioral health treatment, such as psychotherapy and counseling
  • Mental and behavioral health inpatient services
  • Substance use disorder or abuse treatment

Pre-existing mental and behavioral health conditions are covered, and spending limits aren’t allowed. Your specific behavioral health benefits will depend on the state you live in and the health plan you choose. Check your health plan to see what’s covered.

It’s Not too Late to Enroll

You still have time to enroll in an ACA marketplace plan. The deadline to enroll is January 15. Your coverage will start February 1. American Exchange can help you enroll. We can also enroll you in a vision or dental plan. Call us today. 

Call American Exchange today at 888.995.1674 or email us at  rcm@americanexchange.com