Essential Health Benefits in Marketplace Plans

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Essential Health Benefits in Marketplace Plans

Marketplace health insurance plans provide a comprehensive range of essential health benefits. These benefits ensure individuals have access to necessary and varied medical services. Here are the 10 essential benefits every Marketplace plan includes:

  • Ambulatory Patient Services: Outpatient care that doesn't require hospital admission, such as consultations and minor procedures, falls under this benefit.
  • Emergency Services: This benefit guarantees immediate care in critical situations, without concerns about network status or pre-authorization.
  • Hospitalization: The health plan covers any services associated with a hospital stay, including surgeries and overnight care.
  • Pregnancy, Maternity, and Newborn Care: These services provide comprehensive support for mother and child, from pregnancy through childbirth, as well as newborn care.
  • Mental Health and Substance Use Services: This includes treatments like counseling and psychotherapy, providing essential support for mental and physical well-being.
  • Prescription Drugs: Marketplace health plans cover necessary medications, supporting ongoing health and treatment.
  • Rehabilitative and Habilitative Services and Devices: These services assist individuals recovering from injuries, or those with disabilities, aiding in their rehabilitation or skill acquisition.
  • Laboratory Services: The plan covers essential lab tests for diagnosis and treatment planning.
  • Preventive and Wellness Services, and Chronic Disease Management: These services aim to avert illnesses and manage chronic conditions.
  • Pediatric Services: This benefit addresses the needs of children. It includes care like oral and vision services. Note: adult dental and vision are not covered.

While these are the foundational benefits, specific coverage can vary by state. Additionally, some health plans might offer extra benefits such as adult dental and vision care, or wellness programs.

Essential health benefits can differ slightly by state, so it's vital to know your state's specifics.

You should also consider health plans that offer additional benefits that could be valuable for your employees. Evaluate what each plan provides, ensuring it meets your employees' needs.

Common Questions Explained

Do benefits vary across the United States?

Yes. Some states require insurers to cover additional services and procedures. There can even be small differences within the same state.

When you compare plans in the Marketplace, you'll see the benefits each plan offers.

What if an employee needs a treatment that's not listed?

Marketplace plans cover a range of services within each benefit category, so it's likely that the necessary treatment is included. Check with the insurance provider for detailed coverage.

Are there additional costs for these benefits?

Yes. All Marketplace plans have deductibles, copayments, and other out-of-pocket costs that apply to most covered services.

Some preventive services are free, and some plans cover other services without out-of-pocket costs.

How do self-insured companies fit in?

Self-insured plans might not offer all these benefits, so it's essential to review your specific plan details.

What about abortion coverage?

Abortion service coverage varies based on state laws and individual plan details.

What about grandfathered plans?

Plans purchased before March 23, 2010, may not include all essential health benefits. These plans should be reviewed individually.

By understanding the coverage provided by Marketplace health insurance plans, you can offer relevant and compliant health benefits, aligned with your employees' needs.

Offering health benefits is a major decision for businesses. Use as a resource to learn more about health insurance products and services for your employees.

I’m a small business, how do I provide health insurance coverage for my employees?

The Small Business Health Options Program (SHOP) helps businesses provide health coverage to their employees.

SHOP insurance is generally available to employers with 1-50 full-time equivalent employees (FTEs). If you have fewer than 25 employees, you may qualify for the Small Business Health Care Tax Credit, if you buy SHOP insurance. Learn more about SHOP eligibility rules and the Small Business Health Care Tax Credit.

How to know if you qualify for SHOP? 

SHOP insurance is available to employers with 1-50 full-time equivalent (FTE) employees in most states. In some states, employers with 1-100 employees qualify.

You must offer SHOP coverage to all of your full-time or FTE employees. Generally, these are employees working 30 or more hours per week on average.

In many states, at least 70% of employees offered coverage must accept the offer, or be covered by another form of coverage, for the employer to participate. (Employers who apply for or renew SHOP coverage between November 15 and December 15 each year can enroll without meeting this requirement.)

You must have an office or employee work site within the state whose SHOP you want to use.

Download the Employer Guide to SHOP Insurance