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The Affordable Care Act Benefits


You may not know just how many benefits the Affordable Care Act provides. The ACA has requirements for what all nongrandfathered health insurance plans must cover, known as the Essential Health Benefits. Some of these services are provided at no cost to you, while others may require a co-insurance payment. It's always best to check your specific plan for cost and referral requirements.

  1. Ambulatory patient services: Also known as outpatient care, this includes treatment that you receive without being admitted to a hospital. It also includes home and hospice care. Some plans limit how long you have access to some services; typically, the maximum is 45 days of home care.
  2. Emergency services: Generally, this includes trips to the emergency room that are made necessary by an accident or sudden illness. Any transportation by ambulance must also be covered. Under the ACA, you cannot be penalized for going out of network or for not getting prior authorization for emergency care.
  3. Hospitalization: Under the ACA, tests, medication, care, and rooming in a hospital must all be covered. Surgeries, transplants, and care performed in a skilled care facility, such as a nursing home, are also covered. It should be noted that some plans may put a 45-day cap on stays in skilled care facilities.
  4. Maternity and newborn care: The ACA covers care throughout pregnancy and delivery, as well as care for newborn babies.
  5. Pediatric services: The ACA stipulates that infants and children should have access to well-child visits as well as the recommended vaccines. Children under 19 must also have dental and vision coverage, which includes two dental exams, a vision exam, and corrective lenses each year.
  6. Mental health and addiction treatment: Care needed to diagnose and treat a mental illness or substance-abuse disorder falls under this category. To that end, counseling, treatment, and psychotherapy must all be covered, although plans can limit the coverage to 20 days per year.
  7. Preventive, wellness, and chronic-disease services: Tests, physicals, screenings, and immunizations that are needed to detect and prevent the development of certain conditions, including cancer, must be covered. This also includes treatment for chronic conditions such as asthma and diabetes.
  8. Prescriptions: Medications needed to treat a condition or illness must be covered, but insurers are allowed to set limits on this coverage, such as allowing only generic drugs. Usually, over-the-counter medications will not be covered, even if your doctor writes a prescription.
  9. Laboratory services: Treatment or screening needed to diagnose or monitor a condition must be covered. This includes mammograms and prostate exams.
  10. Rehabilitative services and devices: Plans must cover any therapy or device needed to help you develop or recover skills. Each year, 30 visits to a physical therapist, occupational therapist, or chiropractor must be provided for those who need them. You must also have access to 30 visits with a speech therapist, as well as access to cardiac and pulmonary rehab.

These Affordable Care Act benefits are designed to keep you and your family safe and healthy. When you know what coverage you have, it makes it easier to work with your doctor to ensure you are making good health decisions.

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