Re-posted on 7-11-18

What are “Essential Health Benefits” and who has to have them?  From 1/1/2014 on, all new health plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below, in order to avoid a tax penalty. 

Qualified Health Plans MUST cover these 10 items without any lifetime or annual limits on these “Essential Health Benefits.”    There are exceptions to those that have to buy these plans.  Those folks that have a State or Federal plan (Medicare, Medicaid, VA, Tricare, CHIP etc.) or are a part of an Employer Group that provides benefits or are Grandfathered or that the insurance is unaffordable won’t need to buy.

Post 3-10-14 | Essential Health Benefits

All the rest of us, unless we are Exempt our plan must cover these benefits to be the correct kind of insurance to avoid paying the tax penalty, or until our insurance company tells us our current policy we have now (only if it’s a major medical policy) renews and we must buy a “Qualified Health Plan” that has the following benefits:

Health Insurance - Ten Essential Health Benefits

♦ Ambulatory patient services  (clinics, doctors office, same-day surgery centers, etc.)

♦ Emergency services

♦ Hospitalization

♦ Maternity and newborn care

♦ Mental health and substance use disorder services, including behavioral health treatment

♦ Prescription drugs

♦ Rehabilitative and habilitative services and devices

♦ Laboratory services

♦ Preventive and wellness services and chronic disease management

♦ Pediatric services, including dental and vision care (see below)

Dental for “Pediatrics” means anyone under the age of 19 must be offered a dental plan ON Exchange, and a built in dental plan OFF Exchange.

Vision for children under the age of 19 is covered, 1 visit per year, 1 pair of glasses per year are covered. The pediatric vision has to be covered on and off of the exchange.

Your insurance company must also allow members to request to have a drug covered that they need that the insurance company does not cover.

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