1. Ambulatory Patient Services

This refers to the type of care you get without being admitted to a hospital. It may also be known as outpatient care. This includes visits to your primary care provider (PCP) and other in-network care providers.

How these services are covered by a plan is likely to vary depending on the type of service. For example, if you visit your PCP, you may have to pay a copay, but if you have outpatient surgery, you may have to pay your deductible and coinsurance instead.

2. Emergency Services

If you need immediate medical care, you can get care from the nearest hospital or emergency center. Marketplace insurance plans are required to help with the cost, even if the nearest emergency room is not in your network.

Although most people probably don’t expect to have medical emergencies, it’s best to understand your coverage, so you’re prepared should an emergency arise. You can find the details of a plan’s emergency and urgent care coverage in the “Summary of Benefits and Coverages” document.

3. Hospitalization

Hospitalizations, such as for a preauthorized surgery, are covered by Marketplace plans, but you’ll likely want to ensure you schedule your care at an in-network facility. In addition, you may have to pay a deductible and copays or coinsurance before your health plan begins to pay.

4. Pregnancy, Maternity and Newborn Care

Even if you are already pregnant when you choose your health insurance, Marketplace plans cover pregnancy and childbirth. If you are shopping for Marketplace insurance and are currently pregnant or planning to become pregnant, be sure to check out the “Summary of Benefits and Coverages” documents for the plans you’re considering.

5. Mental Health and Substance Use Disorder Services

Plans must provide some coverage for outpatient treatment, such as counseling and psychotherapy. They’re also required to provide coverage for inpatient services. In both cases, prior authorization may be required.

For best coverage, you may want to use in-network providers or facilities, but some types of plans may provide some out-of-network coverage. You can learn more by reviewing the “What You Will Pay” columns of a plan’s “Summary of Benefits and Coverages” document.

6. Prescription drugs

Medications prescribed by a care provider are covered, but your part of the cost will vary depending on the plan and the medication. If you take a prescription drug, be sure to check the plan’s drug list, known as a formulary, to verify that your medication is included.

The formulary’s “drug tier” column helps you understand your costs. Most health insurance plans pay different amounts for the different tiers, and that means what you pay out-of-pocket may vary for the different tiers as well.

7. Rehabilitative and habilitative services and devices

If you need services, such as physical therapy, and/or devices to help with injuries, disabilities or chronic conditions, your insurance plan will provide some coverage to help you gain or recover skills. Prior authorization may be required for some services.

8. Laboratory services

Diagnostic X-rays and various lab tests, such as bloodwork or urine tests, are covered, but prior authorization may be required. And you may have to pay a copay or coinsurance. However, if tests are considered preventive screenings, they may be covered at no cost.

9. Preventive and wellness services as well as chronic disease management

Most health plans must cover three sets of preventive services – for all adults, for women, and for children. These are covered at no cost, even if you haven’t met your deductible, but you may need to see in-network providers. The purpose of these preventive services is to help you maintain your best health and avoid complications, so it’s important to take advantage of the annual checkups, vaccinations and health screenings.

10. Pediatric services, including vision care

Healthcare for all kids on your plan is covered. Preventive services may be covered at no cost, but other services may be subject to copays and coinsurance. An annual eye exam and glasses for the children on your plan may also be covered.

Although each of these essential health benefits are covered, the out-of-pocket costs depend on your plan. If you’re shopping for plans, use the “compare” tool to see an overview of how each plan you’re considering covers these benefits. And you can get even more information in each plan’s “Summary of Benefits and Coverages.”

Questions about the 10 Essential Health Benefits