What are the PPACA Essential Health Benefits?

02 June 2014 |

The new Health Insurance Marketplace opened for business under the Patient Protection and Affordable Care Act (PPACA) – otherwise known as Obamacare – and its arrival has been under a cloud of controversy and misunderstanding. In all the confusion, the many positive aspects of the PPACA have often been overlooked. One important benefit of the Obamacare package for all US citizens and permanent residents is newly-improved access to an affordable, quality healthcare insurance package that covers certain essential benefits. From January 1 2014, all insurance packages sold in the Health Insurance Marketplace must provide cover for 10 essential health benefits. Read on to find out what Marketplace healthcare insurance covers and the 10 essential healthcare benefits under Obamacare.

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Covered Benefits under PPACA

A benefit means that a certain healthcare expense is covered by the health insurance plan. Different health insurance policies offer different benefits. One plan will provide cover for dental work, for example, while another will have coverage for prescription drugs. If the benefit is not covered under the plan then you are responsible for paying for the treatment involved, or a portion of the cost. Usually the types of benefits offered by the policies affect how expensive the insurance is – traditionally, the greater the number of benefits, the more expensive the policy.

Under the PPACA, 10 different healthcare benefits must be offered at no extra cost. These benefits are exactly what the name implies – essential. They do not cover any elective treatments or non-essential procedures and are designed to provide full coverage for optimum health.

List of 10 Essential Health Benefits

Obamacare’s 10 essential health benefits include:

1. Ambulatory patient services: This is the outpatient care you get without being admitted to a hospital – otherwise known as outpatient care. For example, you get this type of treatment when you walk into a doctor’s office, visit an outpatient surgery center for treatment where you are not admitted for the night, or use home health services.

2. Emergency services: This includes a visit to the emergency room for emergency treatment concerning conditions that could result in death or serious disability if not treated promptly. Accidents and sudden serious illness are ER procedures. PPACA plans must cover emergency treatment including transport by ambulance.

3. Hospitalization: You are covered for the time spent in hospital for an unexpected accident or illness when you are being treated, which also includes surgery for the condition.

4. Maternity and newborn care: Plans cover care for the mother before birth – during pregnancy, otherwise known as prenatal care – during the labor and associated procedures, and after the delivery. Also included is the care for the newborn baby.

5. Mental health and substance use disorder services: Included under this essential benefit are inpatient and outpatient services related to the evaluation, diagnosis, and treatment of mental health conditions or substance abuse disorders. The essential benefit also applies to behavioral health treatment including psychotherapy and counselling.

6. Prescription drugs: Prescription drugs are medications and devices prescribed by a doctor for the patient, which treat a condition or illness. These could be antibiotics for an infection, or treatment for high blood pressure. There are some limitations, and you will need to use the medication listed in each classification. Over-the-counter medications will not normally be covered. Generic drugs only may be covered.

7. Rehabilitative and habilitative services and devices: Rehabilitative services are for people recovering abilities and skills such as the ability to speak after a stroke. Habilitative services are for developing certain skills such as speech in young children. Also included are occupational therapy and physical therapy following accident or illness. There may be limits set on the number of visits per year.

8. Laboratory services: This is the testing carried out by labs that allow doctors to diagnose a condition and can include the tests required to monitor a condition. Screenings and tests include breast cancer screenings, blood work, prostate exams, and other essential tests.

9. Preventive and wellness services and chronic disease management: The procedures designed to detect or to prevent certain conditions like cancer and the treatment required to care for a person with a chronic condition such as asthma.

10. Pediatric services: The care and treatment provided to children and infants, from birth upwards. These include regular well-child visits plus vaccinations and immunizations.

While every plan that qualifies under the PPACA and is offered for sale in the Health Insurance Marketplace must offer these 10 benefits, the scope of the services within each category will vary – take a look at some of the different options while you decide which one is best for you and your family.