Co-Founder, TermInsuranceBrokers.com, Goldenzweig Financial Group, Las Vegas, Nevada
The benefits under each plan varies by company and metal level (bronze, silver, gold, and platinum - there's also a catastrophic plan available to individuals under age 30). However, every plan has a set of 10 essential health benefits that they must meet, but carriers have the option to offer coverage above and beyond the essential benefits (the metal level is the big indicator on that).The essential health benefits that every plan must meet are:
1) Ambulatory Patient Services – Health care services without being admitted to a hospital (e.g. visiting a doctor’s office or a clinic, home health services, and hospice care – some plans may limit home health and hospice care benefits to no more than 45 days).
2) Emergency Services – Care of conditions requiring immediate treatment (typically at an emergency room), including ambulance transportation. You also can’t be penalized for going to an out-of-network hospital.
3) Hospitalization – Care provided during a hospital visit, including services provided by doctors, nurses, and other hospital staff, medical tests, medications given during your stay, as well as room and board. Care received in a skilled nursing facility is also included in hospitalization coverage (note: some plans limit skilled nursing facility benefits to no more than 45 days).
4) Laboratory Services – Tests a doctor completes to help diagnose an injury, illness, or other medical condition, or to monitor the progress of a treatment. Some preventative screenings may be fully covered.
5) Maternity and Newborn Care – Care women receive during pregnancy, including prenatal care, in labor, delivery and post-delivery, and care for newborn babies.
6) Mental Health Services and Addiction Treatment – Inpatient and Outpatient care that evaluates, diagnoses, and treats mental health conditions and substance abuse disorders (some plans may limit coverage to 20 days per year).
7) Rehabilitative Services & Devices – Rehabilitative and habilitative services and devices to help regain mental and physical skills that were lost due to injury, disability, or a chronic condition. Each plan has to provide 30 visits per year for physical or occupational therapy, speech therapy, cardiac or pulmonary rehabilitation, and chiropractor visits.
8) Pediatric Services – Care provided to children, including vaccines and immunizations. For children under the age of 19, dental and vision care must be offered – this includes two routine dental exams, an eye exam and corrective lenses each year.
9) Prescription Drugs – Medications prescribed by a doctor to treat a medical condition or illness. At least one prescription drug must be covered in each category and classification.
10) Preventive and Wellness Services and Chronic Disease Treatment – care includes physicals, immunizations, and certain types of screenings designed to prevent or detect certain medical conditions as well as care for chronic conditions such as diabetes and asthma.
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1) Ambulatory Patient Services – Health care services without being admitted to a hospital (e.g. visiting a doctor’s office or a clinic, home health services, and hospice care – some plans may limit home health and hospice care benefits to no more than 45 days).
2) Emergency Services – Care of conditions requiring immediate treatment (typically at an emergency room), including ambulance transportation. You also can’t be penalized for going to an out-of-network hospital.
3) Hospitalization – Care provided during a hospital visit, including services provided by doctors, nurses, and other hospital staff, medical tests, medications given during your stay, as well as room and board. Care received in a skilled nursing facility is also included in hospitalization coverage (note: some plans limit skilled nursing facility benefits to no more than 45 days).
4) Laboratory Services – Tests a doctor completes to help diagnose an injury, illness, or other medical condition, or to monitor the progress of a treatment. Some preventative screenings may be fully covered.
5) Maternity and Newborn Care – Care women receive during pregnancy, including prenatal care, in labor, delivery and post-delivery, and care for newborn babies.
6) Mental Health Services and Addiction Treatment – Inpatient and Outpatient care that evaluates, diagnoses, and treats mental health conditions and substance abuse disorders (some plans may limit coverage to 20 days per year).
7) Rehabilitative Services & Devices – Rehabilitative and habilitative services and devices to help regain mental and physical skills that were lost due to injury, disability, or a chronic condition. Each plan has to provide 30 visits per year for physical or occupational therapy, speech therapy, cardiac or pulmonary rehabilitation, and chiropractor visits.
8) Pediatric Services – Care provided to children, including vaccines and immunizations. For children under the age of 19, dental and vision care must be offered – this includes two routine dental exams, an eye exam and corrective lenses each year.
9) Prescription Drugs – Medications prescribed by a doctor to treat a medical condition or illness. At least one prescription drug must be covered in each category and classification.
10) Preventive and Wellness Services and Chronic Disease Treatment – care includes physicals, immunizations, and certain types of screenings designed to prevent or detect certain medical conditions as well as care for chronic conditions such as diabetes and asthma.