Group Health Plan Benefits

Essential Health Benefits

Individual and small group plans must include items and services within these 10 categories:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, and 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

If an insurer offers a qualified health plan, they must also offer a child-only plan at the same level of coverage.

Pre-existing Condition Requirement

Under the Affordable Care Act, you cannot be denied coverage, charged more, or denied treatment based on your health status or because of a pre-existing condition like asthma, diabetes or cancer. Medicaid and the Children’s Health Insurance Program (CHIP) also cannot refuse coverage or charge you more because of a pre-existing condition.

The exception to this rule is for grandfathered individual health insurance plans, which do not have to cover pre-existing conditions. Individuals who have one of these plans can switch to a Marketplace plan during open enrollment and get coverage for any pre-existing conditions.

Preventive Services for Adults, Women and Children

Free Preventive Services for Adults

All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

This applies only when these services are delivered by a network provider.

• Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
• Alcohol Misuse screening and counseling
• Aspirin use to prevent cardiovascular disease for men and women of certain ages
• Blood Pressure screening for all adults
• Cholesterol screening for adults of certain ages or at higher risk
• Colorectal Cancer screening for adults over 50
• Depression screening for adults
• Diabetes (Type 2) screening for adults with high blood pressure
• Diet counseling for adults at higher risk for chronic disease
• Hepatitis B screening for people at high risk, including people in countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
• Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 – 1965
• HIV screening for everyone ages 15 to 65, and other ages at increased risk
• Immunization vaccines for adults — doses, recommended ages, and recommended populations vary:
  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza (Flu Shot)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella
• Lung cancer screening for adults 55 – 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
• Obesity screening and counseling for all adults
• Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
• Syphilis screening for all adults at higher risk
• Tobacco Use screening for all adults and cessation interventions for tobacco users

Preventive Health Services for Women

All Marketplace health plans, and many other plans, must cover additional preventive health services for women, when provided by an in-network provider, without charging a co-payment or coinsurance, even if you have not met your yearly deductible.

• Anemia screening on a routine basis for pregnant women
• Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer
• Breast Cancer Mammography screenings every 1 to 2 years for women over 40
• Breast Cancer Chemoprevention counseling for women at higher risk
• Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
• Cervical Cancer screening for sexually active women
• Chlamydia Infection screening for younger women and other women at higher risk
• Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
• Domestic and interpersonal violence screening and counseling for all women
• Folic Acid supplements for women who may become pregnant
• Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
• Gonorrhea screening for all women at higher risk
• Hepatitis B screening for pregnant women at their first prenatal visit
• HIV screening and counseling for sexually active women
• Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
• Osteoporosis screening for women over age 60 depending on risk factors
• Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
• Sexually Transmitted Infections counseling for sexually active women
• Syphilis screening for all pregnant women or other women at increased risk
• Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
• Urinary tract or other infection screening for pregnant women
• Well-woman visits to get recommended services for women under 65

Preventive Health Services for Children

All insurance plans purchased through the Marketplace, and many other plans, including Medicaid, must cover the following list of preventive services for children without charging a copayment or coinsurance, even if you have not met your yearly deductible.

• Alcohol and Drug Use assessments for adolescents
• Autism screening for children at 18 and 24 months
• Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years,5 to 10 years, 11 to 14 years, 15 to 17 years.
• Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
• Cervical Dysplasia screening for sexually active females
• Depression screening for adolescents
• Developmental screening for children under age 3
• Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
• Fluoride Chemoprevention supplements for children without fluoride in their water source
• Gonorrhea preventive medication for the eyes of all newborns
• Hearing screening for all newborns
• Height, Weight and Body Mass Index measurements for children at the following ages:0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
• Hematocrit or Hemoglobin screening for children
• Hemoglobinopathies or sickle cell screening for newborns
• HIV screening for adolescents at higher risk
• Hypothyroidism screening for newborns
• Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:
  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus
  • Inactivated Poliovirus
  • Influenza (Flu Shot)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Rotavirus
  • Varicella
• Iron supplements for children ages 6 to 12 months at risk for anemia
• Lead screening for children at risk of exposure
• Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
• Obesity screening and counseling
• Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
• Phenylketonuria (PKU) screening for this genetic disorder in newborns
• Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
• Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
• Vision screening for all children.