Two federal requirements shape what a marketplace health plan has to cover. The first sets the categories of care every plan must include. The second requires a defined list of preventive services to be covered with no cost sharing at all.
Both are widely misunderstood, and the second one in particular is a benefit many people have and do not use.
The ten categories
Non-grandfathered individual and small group coverage must cover essential health benefits in ten categories:
- Ambulatory patient services, meaning outpatient care you receive without being admitted to a hospital
- Emergency services
- Hospitalization, including surgery and overnight stays
- Pregnancy, maternity and newborn care, both before and after birth
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices, which help people recover or gain skills after injury, disability or a chronic condition
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care for children
Every plan shown on the marketplace includes these, at every metal level, including catastrophic plans, and regardless of network type. A bronze HMO and a platinum PPO cover the same ten categories. What differs between them is the cost sharing and the provider network, not the scope of covered categories. That distinction is covered in health plan metal tiers explained.
What the categories do and do not settle
The ten categories are a floor, not a detailed benefit schedule.
The specifics vary by state. Each state has an essential health benefits benchmark plan that fills in what the broad categories mean in practice. Two plans in different states can both cover "rehabilitative services" and differ on visit limits, covered therapy types or authorization requirements.
Adult dental and vision are not included. Pediatric dental and vision are essential health benefits; adult dental and vision are not. Plans may offer them, and standalone dental plans are sold on many marketplaces, but they are optional rather than required.
Coverage is not the same as no cost. A category being covered means the plan pays its share after your deductible, copay and coinsurance apply. The mechanics are covered in deductible, copay, coinsurance and out-of-pocket max.
Networks still apply. A covered benefit received out of network may be paid at a reduced rate or not at all, depending on plan type.
Prior authorization still applies. Many plans require approval before certain services, and a covered service can still be denied for lack of authorization or a determination that it was not medically necessary. If that happens, appealing a denied health insurance claim describes what you can do about it.
Preventive services at no cost sharing
Most health plans, including marketplace plans, must cover a set of preventive services with no copay, no coinsurance and no deductible, when delivered by an in-network provider. This applies even if you have not met your deductible for the year.
The services are grouped into three lists.
For adults, the list includes items such as blood pressure screening, cholesterol screening for certain ages and risk groups, colorectal cancer screening, type 2 diabetes screening, depression screening, immunizations recommended by the federal advisory committee, tobacco use screening and cessation interventions, and screening and counseling for alcohol misuse.
For women, the list adds items such as mammograms for women in the recommended age range, screening and counseling for interpersonal and domestic violence, bone density screening at certain ages, breastfeeding support and supplies, contraceptive methods and counseling, and prenatal care.
For children, the list includes well-baby and well-child visits, immunizations, developmental and autism screening, vision and hearing screening, and behavioral assessments.
The actual covered items are set by federal recommendations and updated as evidence changes. Newly recommended services generally must be covered without cost sharing starting with plan years beginning about a year after the recommendation. HealthCare.gov maintains the current lists, and they are the place to check rather than a summary written at some earlier date.
Why a "free" preventive visit sometimes generates a bill
This is one of the most common billing complaints, and the explanation is usually the same.
A screening and a diagnostic test are billed differently. A screening colonoscopy for someone with no symptoms is preventive. The same procedure ordered because of symptoms, or a follow-up after an abnormal result, may be billed as diagnostic and subject to normal cost sharing.
A preventive visit can turn into an office visit. If you raise a new problem during a wellness visit and the provider evaluates and treats it, that portion may be billed separately and be subject to cost sharing.
Out-of-network providers are outside the requirement. The no-cost-sharing rule generally applies to in-network care.
The specific service may not be on the list. Not every test that sounds preventive is on the federal recommendation lists.
If you receive a bill for something you expected to be free, ask the provider's billing office how the visit was coded and ask your plan how it processed the claim. Coding corrections are common, and a mismatch between the two documents is often the whole problem.
Getting the benefit you already have
A few practical habits:
- Confirm the provider is in network before a preventive visit, not after.
- Say the word "preventive" when you schedule, and ask whether the specific services planned are on your plan's no-cost-sharing list.
- Ask before adding a new concern to a wellness visit whether that will change how the visit is billed. It may still be the right thing to do, but you will not be surprised.
- Check your plan's own preventive list, since plans may cover more than the federal minimum but rarely less.
Covered benefits, state benchmark differences, network rules and authorization requirements vary by insurer, by plan and by state, and the plan documents control. Your plan's Summary of Benefits and Coverage, the insurer, a licensed agent, or your state Department of Insurance can answer questions about your own coverage.
To get connected with licensed carriers and agents offering health plans in your area, you can request health insurance quotes.