Prior to the Affordable Care Act’s (ACA) passage, this question would have been substantially more difficult to answer. Up until its passage, each health insurance plan could include or exclude whatever they choose. The ACA brought clarity and regulatory standards with regard to the required types of coverage offered to members. It requires that all permanent health insurance plans provide coverage for the following ten “essential benefits”:
Ambulatory Patient Services: When you receive non-hospital outpatient medical care, which may include advanced procedures and technological services. This includes such services as diagnosis, observation, consultation, treatment, intervention, and rehabilitation services.
Emergency Services: Your provider can’t require that you contact a hospital prior to an emergency to see if they are an approved hospital. If you’re experiencing a medical emergency, proceed to the closest hospital available. Health insurance coverage must include emergency services provided from any hospital, regardless of whether they are in-network or not.
Hospitalization: If you are required to stay overnight in a hospital, or find yourself in need of a surgery, or prescription drugs while in the hospital, then your health provider is required to provide coverage.
Pregnancy, Maternity and Newborn Care: Yes, pregnancy is a required coverage by the ACA mandate and that includes before birth and after birth care. It also includes labor and pregnancy complications.
Mental Health and Substance Abuse Treatments: Health insurance providers now must provide coverage for substance abuse and behavioral therapy, as well as inpatient mental health services. There is also protection that prevents insurance companies from placing lifetime limits for any specific disorder or substance abuse issue.
Prescription Drugs: Health insurance providers can’t exclude coverage for prescription drugs. They do have an option referred to as “step therapy”, which allows them to require patients to try comparable medications which cost less before agreeing to cover more expensive or potentially habit forming prescription drugs.
Rehabilitative Services and Devices: These include therapies such as physical therapy, occupational therapy and mobility devices.
Laboratory Services: Health insurance providers must provide coverage for outpatient bloodwork and imaging that you receive in a hospital or medical facility such as an upper GI scan or x-rays.
Preventive Services and Wellness Screenings: Many health insurance plan providers offer these services for free and they include services such as annual physicals, vaccinations and booster shots.
Pediatric Services: Insurance providers are required to include health, vision and dental services to children covered on your plan. It’s important to note that this only applies to children and the ACA does not provide a mandate on these coverages for adults. You may find them offered separately as an add-on service to include adult coverage for an additional cost.
Your plan must also include the following benefits for women:
- Breastfeeding Support: This includes counseling and equipment for nursing mothers.
- Birth Control: ACA-compliant plans must include prescribed FDA-approved contraceptive methods. This includes emergency contraceptives but does not include drugs intended to terminate an already viable pregnancy.
Your employer may be exempt from covering certain contraceptives if you work for a house of worship or a religious non-profit.
What Does Health Insurance Not Cover?
Most health insurance plans don’t cover the following benefits:
Male Birth Control: Vasectomies and barrier methods for men are not covered under most plans. While female birth control is considered an essential benefit, male birth control is not.
Travel Vaccinations: Travel vaccinations are viewed as elective prevention and not covered under most plans.
Vision and Dental Coverages: These coverages are required to be provided for children but not adults. You may want to check to see if your provider offers this as an add-on service.
Weight Loss Surgery: Bariatric surgery is not required by the federal mandate but many insurance providers do elect to include this coverage. Be sure to contact your health provider to confirm if it’s covered before enrolling, if you or a loved one is considering this procedure.
Cosmetic Surgery: Since cosmetic surgeries are not medically necessary and are based on elective selection, cosmetic procedures are not covered by health insurance mandate.
As you can see by reviewing the above list, the benefits which are mandated and required to be included by coverage providers are each based on the concept of essential services and/or essential benefits. If a procedure or service is not deemed essential or necessary, it generally is not going to make the list and be covered by most insurance providers. Keep in mind, the above non-covered medical procedures and services is simply a partial list of medical treatments which are not covered. It’s by no means a comprehensive list and only to be used as a basic list of common areas not covered. If you find yourself in any doubt, it’s always best to contact your health insurance provider and inquire with them about specific plan coverages.
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