Understanding the Health Care Law’s 10 Essential Benefits

Understanding the Health Care Law’s 10 Essential Benefits

Last January, the Patient Protection and Affordable Care Act (ACA) greatly expanded the healthcare benefits available to Americans. The law set certain standards that all insurers must meet as well as mandated that all ACA compliant health insurance plans cover 10 essential benefits.

1. Ambulatory Patient Services

All health insurance plans must provide outpatient care. Networks and available doctors will vary by plan, but the ACA states that the network’s size must be “sufficient” to meet demand.

2. Prescription Drugs

While many previous insurance plans required add-on prescription drug coverage, the ACA mandated that all individual and small-group plans must cover at least one drug in every category and class of approved medications. While the cost for these drugs will vary (some plans require you to meet a separate drug deductible before you can benefit from price reductions), they will count towards your out-of-pocket maximums.

3. Emergency Care

In many cases, previous health insurance plans already covered a portion of emergency room visits. Under the ACA, however, they can no longer you to obtain preauthorization before seeking treatment, nor can they charge you more if you must go to an out-of-network emergency facility.

4. Mental Health Services

While many old health insurance plans did not cover mental or behavioral health services, the ACA mandates that all new plans must include these benefits for reasonable copays. However, there may be a limit set on the number of covered therapy visits you can make each year.

5. Hospitalization

Under the ACA, all compliant health insurance plans must cover at least a portion of hospitalization costs—and all costs if you’ve reached your out-of-pocket limit. Hospitalization coverage also includes care received in a skilled nursing facility, though some plans may limit that coverage to no more than 45 days.

6. Rehabilitative Services

Compliant individual and small-group health insurance plans must cover rehabilitative services (such as speech therapy after a stroke or physical therapy after a knee replacement) as well as habilitative services (such as speech therapy for children) and associated devices. Plans must cover 30 visits each year for physical or occupational therapy as well as speech therapy and cardiac or pulmonary rehab.

7. Preventative and Wellness Services

ACA compliant plans must allow you a free wellness visit with your doctor each year as well as cover 50 additional preventative services at no extra cost. These include a number of cancer screenings, immunizations and other health screenings. You can find a complete list here.

8. Laboratory Services

All new individual and small-group insurance plans must cover testing used to diagnose injuries, illness and conditions and monitor the effectiveness of treatment. While the preventative screenings in the list mentioned above are free, you will usually be required to pay a fee for diagnostic tests.

9. Pediatric Care

In addition to well visits and recommended immunizations, plans must include additional coverage for children under the age of 19, such as twice-yearly dental cleanings, dental x-rays, fillings and medically necessary orthodontic treatment. They must also cover an eye exam and one pair of glasses or set of contacts each year.

10. Maternity and Newborn Care

Individual and small-group plans must provide prenatal care at no additional cost—something nearly unheard of in old insurance plans. They must also cover childbirth and newborn infant care, though some benefits are subject to deductibles, copays or coinsurance.


The open enrollment period for 2015 healthcare coverage is about to begin (it runs November 15-February 15), so now is the time to start thinking about renewing or changing your health insurance plan. If you need assistance navigating the marketplace or want to discuss your options, contact your insurance agent today.

What You Need to Know About Ebola

What You Need to Know About Ebola

If the mere mention of the Ebola virus terrifies you, you’re not alone. While we’ve yet to see more than a handful of cases in the U.S., a number of state governors—and the pentagon—are mandating monitoring and/or quarantines for healthcare professionals, military troops and foreign visitors who may have had contact with infected individuals while in the West African nations of Guinea, Liberia and Sierra Leone.

According to the World Health Organization (WHO), the number of reported Ebola cases in the current outbreak topped 10,000 as of mid-October—and nearly 5,000 individuals had died of confirmed, suspected or probable cases. However, almost all of these deaths were in the three West African nations at the center of the epidemic.

Within the U.S., there has been only one death. Experts from the Centers for Disease Control and Prevention (CDC) have stated repeatedly that the risk of a serious outbreak of Ebola within North America is extremely low, though many Americans are still concerned. If you’re among them, consider these facts you need to know about the virus.

  • Ebola symptoms generally start to show within 21 days of contracting the virus. Most cases develop within eight to 10 days. Until early symptoms—including fever, headache, fatigue and nausea—are present, a person with Ebola is not contagious.
  • Few Americans are actually at risk of contracting Ebola. If you haven’t been to Guinea, Liberia or Sierra Leone recently, and are not a healthcare worker who has participated in the treatment of the few U.S. Ebola cases, there is virtually no way you could have caught it.
  • Ebola is not airborne (like the flu or the common cold virus), nor does it spread through casual contact. Rather, you must have direct contact with the bodily fluids of someone showing symptoms. Bodily fluids include saliva, sweat, tears, vomit, blood, urine and feces. The two nurses who contracted the virus while treating an Ebola patient in Dallas earlier this month were dealing with copious quantities of these fluids. (Incidentally, they both survived with treatment).
  • Should Ebola become more widespread, you can take steps to reduce your chances of contracting it. You should already be taking the first two if you want to minimize your risks of catching cold viruses and the flu. These steps include:
    • Frequently washing your hands with soap and water or an alcohol-based hand sanitizer
    • Avoiding touching your face, eyes or other mucus membranes with unwashed hands
    • Avoiding contact with blood and other bodily fluids
    • Avoiding items that may have come into contact with an infected person’s blood or bodily fluids (including clothes, bedding and needles)
    • Avoiding handling the bodies of anyone suspected to have died from Ebola