What Marketplace health insurance plans cover
Oct 4, 2017
All plans offered in the Marketplace cover the same set of essential health benefits.
Every health plan must cover the following services:
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Hospitalization (like surgery and overnight stays)
Pregnancy, maternity, and newborn care (both before and after birth)
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
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)
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Plans must also include the following benefits:
Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on your state’s requirements. Plans may offer additional benefits, including:
Medical management programs (for specific needs like weight management, back pain, and diabetes)
When comparing plans, you’ll see exactly what each plan offers.
Are the benefits the same in each state?
What if I need a specific treatment that's not on this list?
Do all types of Marketplace plans cover essential health benefits?
Do I have to pay deductibles and copayments for essential health benefits?
Do I get these benefits if my company is self-insured?
Do I get these benefits if I have a grandfathered plan?
Coverage for pre-existing conditions
October 4 2017
All 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 condition 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.
Pregnancy is covered from the day your plan starts
If you’re pregnant when you apply, an insurance plan can’t reject you or charge you more because of your pregnancy.
Once you’re enrolled, your pregnancy and childbirth are covered from the day your plan starts.
If you have a 2017 health plan & give birth or adopt after you enrolled:
Your child’s birth or adoption qualifies you for a Special Enrollment Period. This means you can enroll in or change plans outside the annual Open Enrollment Period.
Your coverage can start from the date of birth or adoption, even if you enroll up to 60 days afterward.
Exception: grandfathered plans don’t have to cover pre-existing conditions
You can switch to a Marketplace plan that will cover them during Open Enrollment.
You can buy a Marketplace plan outside Open Enrollment when your grandfathered plan year ends, and you’ll qualify for a Special Enrollment Period.
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