What services are/are not covered under ACA-compliant health insurance plans?

The Affordable Care Act requires that individual and small group plans purchased on or after January 1st, 2014 cover ten essential benefits. This applies to plans purchased both on and off the exchange. The ten essential benefits are:

  • Hospitalization
  • Outpatient hospital care and visits to doctors and other medical professionals
  • Emergency services
  • Maternity and newborn care
  • Mental health and substance abuse services
  • Prescription drugs
  • Lab tests
  • Preventive services and chronic disease management, including certain kinds of counseling and screening for blood pressure, obesity, and various types of cancer.
  • Pediatric services, including vision and dental care
  • Rehabilitative and habilitative services

While pediatric dental care is listed among the essential benefits, it may not be included in all plans. Under the Affordable Care Act, plans sold on the exchange are allowed to omit pediatric dental care from their coverage as long as a stand-alone pediatric dental plan is also available. As an enrollee, you will not be penalized for purchasing a plan without pediatric dental and also not opting for the stand-alone version – all that matters is that the option of the stand-alone plan is available to you. One should also keep in mind that even if pediatric dental is part of your plan, services such as orthodontic work may not be covered unless deemed medically necessary.

Services such as adult vision and dental care, chiropractic work, care for autistic persons, and more may be covered under some plans, but are not required.

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