Understanding the ACA's Essential Health Benefits in Missouri
One of the cornerstones of the Affordable Care Act (ACA) is the requirement for health insurance plans to cover a set of Essential Health Benefits (EHBs). These benefits ensure that all health insurance plans offered in the Marketplace, whether through the Health Insurance Marketplace or employer-sponsored plans, provide comprehensive coverage that addresses the diverse healthcare needs of individuals and families. Understanding these benefits is crucial for selecting the right health insurance plan in Missouri.
What Are Essential Health Benefits (EHBs)?
The ACA defines Essential Health Benefits (EHBs) as a specific set of healthcare services that must be covered by health insurance plans. These benefits were designed to improve access to healthcare and ensure that people receive a full range of necessary services without facing excessive out-of-pocket costs.
These benefits cover services that are essential for the health and well-being of individuals across different age groups and life circumstances. In Missouri, as in other states, the following 10 categories of services are considered Essential Health Benefits:
1. Ambulatory Patient Services (Outpatient Care)
Outpatient care refers to services you receive without being admitted to a hospital. This category includes visits to the doctor’s office, minor surgeries, diagnostic tests, and other treatments provided in outpatient settings.
2. Emergency Services
Emergency services are critical for unexpected situations that require immediate attention, such as emergency room visits, ambulance services, and urgent care. Under the ACA, insurance plans must cover emergency services, even if they are out-of-network.
3. Hospitalization
Hospitalization benefits cover stays in a hospital for surgery, illness, or other treatments that require overnight care. The ACA ensures that health insurance plans cover necessary hospital care, including room charges, surgery, and post-operative services.
4. Maternity and Newborn Care
The ACA mandates that health insurance plans must cover maternity and newborn care, including prenatal visits, labor and delivery, and postnatal care. Coverage also extends to the health of newborns after birth, ensuring both the mother and baby are supported throughout the process.
5. Mental Health and Substance Use Disorder Services
Health insurance plans must include coverage for mental health services and substance use disorder treatment, such as counseling, therapy, inpatient care, and substance abuse treatment programs. This coverage is vital for promoting mental wellness and providing support for those facing addiction.
6. Prescription Drugs
Under the ACA, health plans must cover prescription medications. This includes both generic and brand-name drugs that are deemed necessary by your healthcare provider. Prescription drug coverage ensures that individuals can afford the medications they need for chronic conditions or temporary illnesses.
7. Rehabilitative and Habilitative Services and Devices
These services help people recover or improve their ability to function after illness, injury, or disability. Rehabilitative services focus on restoring functions (e.g., physical therapy), while habilitative services help individuals maintain skills and functions they may never have had (e.g., speech therapy, assistive devices).
8. Laboratory Services
Health insurance plans must provide coverage for laboratory services, including blood tests, X-rays, and other diagnostic tests. This ensures that individuals have access to necessary screenings and tests for detecting health conditions early.
9. Preventive and Wellness Services, Chronic Disease Management
Preventive services are designed to help individuals stay healthy and avoid the onset of chronic conditions. These services include vaccinations, screenings, wellness checkups, counseling, and screenings for diseases such as cancer, diabetes, and heart disease.
10. Pediatric Services
For families with children, pediatric services include health care services for children from birth to age 19. This encompasses routine checkups, vaccinations, dental care, vision services, and treatments for childhood illnesses or conditions.
How Does ACA Coverage Work in Missouri?
In Missouri, all health insurance plans available through the Health Insurance Marketplace must adhere to the ACA's Essential Health Benefits requirements. This ensures that no matter what plan you select, you will have access to a comprehensive range of services. Additionally, these benefits cannot be excluded or limited based on pre-existing conditions, and insurance companies cannot charge higher premiums for covering these essential services.
If you are purchasing coverage through the Missouri Health Insurance Marketplace or another ACA-compliant plan, it’s important to carefully review the details of the plan to ensure the benefits are included and that they meet your healthcare needs.
What if I Need Additional Coverage?
While the Essential Health Benefits cover a wide range of necessary services, some individuals may need additional coverage for things like dental care, vision care, or long-term care. Some ACA plans include these services, while others may require a separate supplemental policy.
For example, dental and vision coverage are not included in all Marketplace plans, but many providers offer stand-alone plans for these services. If you need these services, it’s important to shop around and find a plan that meets all of your needs.
Contact Us
Navigating the Essential Health Benefits and finding the right health insurance coverage for your needs can be a complex process. At Riverside Insurance Professionals, we’re committed to helping you understand how the ACA works in Missouri and assisting you in selecting the best coverage based on your health needs and budget. If you have any questions or would like help comparing plans, feel free to reach out.
Phone: (573) 535-6044
Email: Jennifer@RiversideInsuranceProfessionals.com
Office Hours: Monday – Friday, 9:00 AM to 5:00 PM
For more details about the Essential Health Benefits, visit HealthCare.gov.