What Marketplace Health Insurance Plans Cover

All Marketplace health insurance plans are required to cover a comprehensive set of essential health benefits, ensuring you receive necessary care. Here’s a summary of what’s included:

Essential Health Benefits

1. Ambulatory Patient Services:

1. • Outpatient care received without hospital admission.

2. Emergency Services:

• Care for urgent health issues, including emergency room visits.

3. Hospitalization:

• Coverage for surgeries and overnight stays in the hospital.

4. Pregnancy, Maternity, and Newborn Care: 

Includes care before and after birth for both mother and baby.

5. Mental Health and Substance Use Disorder Services:

• • Treatment for behavioral health issues, including counseling and psychotherapy.

6. Prescription Drugs:

• Coverage for medications prescribed by your healthcare provider.

7. Rehabilitative and Habilitative Services and Devices:

• Services and devices to help recover or improve physical and mental abilities.

8. Laboratory Services:

• Tests and procedures to diagnose and monitor health conditions.

9. Preventive and Wellness Services:

• Includes preventive care and chronic disease management.

10. Pediatric Services:

• Covers oral and vision care for children (adult dental and vision coverage are not essential benefits).

Additional Coverage

Marketplace plans also include:

• Birth Control Coverage:

  • Access to contraceptives and related services.

• Breastfeeding Coverage:

  • Support and supplies for breastfeeding.

Additional Benefits

Beyond essential benefits, some plans may offer:

• Dental Coverage:

  • For routine and major dental care.

• Vision Coverage:

  • Includes eye exams, glasses, and contact lenses.

• Medical Management Programs:

  • Programs for specific needs like weight management, back pain, and diabetes.

Preventive Health Services

Most health plans, including those available through the Health Insurance Marketplace®, must cover a range of preventive services—such as vaccinations and screening tests—at no cost to you.

Important: These services are free only when provided by a doctor or provider within your plan’s network.

Preventive services are categorized into three groups:

• For All Adults
• For Women
• For Children

Coverage for Pre-Existing Conditions

All plans available through the Marketplace must cover treatment for pre-existing medical conditions. This means:

• No Rejection or Extra Charges: Insurance plans cannot deny coverage, charge higher premiums, or refuse to cover essential health benefits for any condition you had before your coverage began.
• Stable Rates: Once enrolled, your plan cannot deny you coverage or increase your rates based solely on your health status.
• Medicaid and CHIP: These programs also cannot refuse coverage or charge more due to pre-existing conditions.

Pregnancy Coverage

• Immediate Coverage: If you're pregnant when you apply for coverage, your plan must include treatment for your pregnancy and childbirth from the day your coverage starts.
• Special Enrollment Period: If you give birth or adopt after enrolling in your Marketplace plan, you qualify for a Special Enrollment Period. This allows you to enroll in or switch plans outside the annual Open Enrollment Period. Coverage for your child can start from the date of birth or adoption, even if you enroll up to 60 days later.

Exception: Grandfathered Plans

Grandfathered plans do not have to cover pre-existing conditions or preventive care. If you have a grandfathered plan and need coverage for pre-existing conditions, you have two options:

1. Switch to a Marketplace Plan: Enroll in a Marketplace plan during Open Enrollment that covers pre-existing conditions.
2. Special Enrollment Period: Buy a Marketplace plan outside Open Enrollment when your grandfathered plan year ends, and you’ll qualify for a Special Enrollment Period.

Dental Coverage in the Marketplace

In the Marketplace, you have the option to choose a health plan with or without dental benefits. If you select a health plan without dental coverage, you can purchase a separate dental plan.

Important: You can only purchase a Marketplace dental plan if you are also buying a health plan at the same time.

Two Ways to Get Dental Coverage:

1.Health Plans with Dental Coverage:

1. • Some Marketplace health plans include dental coverage. You can identify which plans offer dental coverage when comparing options.
   • If you select a plan that includes dental benefits, the premium you pay covers both health and dental services.

2.Separate Dental Plans:

• • Separate dental plans are also available. These can be viewed alongside health plans when shopping in the Marketplace.
  • If you choose a separate dental plan, you'll pay an additional premium, on top of your health plan premium.

Preview Dental Plans: To see available dental plans, click the button below and answer a few questions about your income and household. This will allow you to preview both health plans with dental coverage and separate dental plans.

Dental Plan Categories:

Marketplace dental plans are categorized into two levels:

• High Coverage Level:

  • Higher premiums, but lower copayments and deductibles. This means you’ll pay more monthly but less when receiving dental services.

• Low Coverage Level:

  • Lower premiums, but higher copayments and deductibles. This means you’ll pay less monthly but more when receiving dental services.

When comparing dental plans, review the costs, copayments, deductibles, and covered services for each plan.

Dental Insurance for Adults and Children:

• For Children (18 and Under):

  • Dental coverage is considered an essential health benefit for children. If you’re enrolling a child in health coverage, dental coverage must be available either as part of the health plan or as a separate plan. However, you are not obligated to purchase it.

• For Adults:

  • Dental coverage is not an essential health benefit for adults. Health plans are not required to offer adult dental coverage.

Cancelling Dental Coverage:

• Separate Dental Plan:

  • You can cancel a separate dental plan at any time. Learn how to cancel a separate dental plan while keeping your health coverage.

• Health Plan with Dental Coverage:

  • You cannot remove dental coverage from a health plan once enrolled. However, you can switch to a different health plan with or without dental coverage during:
    • The yearly Open Enrollment Period
    • A Special Enrollment Period if you qualify outside of Open Enrollment

Birth Control Benefits

In the Health Insurance Marketplace®, all plans must cover contraceptive methods and counseling for women as prescribed by a healthcare provider. This coverage is provided without charging a copayment or coinsurance when obtained from an in-network provider, even if you haven't met your deductible.

Covered Contraceptive Methods:

FDA-approved contraceptive methods prescribed by your doctor include:

• Barrier Methods: Diaphragms and sponges
• Hormonal Methods: Birth control pills, patches, and vaginal rings
• Implanted Devices: Intrauterine devices (IUDs)
• Emergency Contraception: Plan B® and ella®
• Sterilization Procedures

Note: Plans are not required to cover drugs that induce abortions or services related to male reproductive capacity, such as vasectomies.

Tip: To confirm if a specific contraceptive method is covered by your plan, review your plan's materials or consult with your employer or benefits administrator.

Rules for Employer-Provided Coverage:

• Religious Employers: Health plans sponsored by certain exempt religious employers, such as churches, are not required to cover contraceptive methods and counseling. If you work for one of these employers and use contraceptive services, you may need to pay out-of-pocket. Contact your employer or benefits administrator for details.

• Non-Profit Religious Organizations: Some non-profit religious organizations, such as non-profit religious hospitals or institutions of higher education that have religious objections to contraceptive coverage, are not required to provide or arrange for contraceptive coverage. In such cases, an insurer or third-party administrator will handle separate payments for contraceptive services. You will have access to these services without additional copayments, coinsurance, or deductibles when provided by an in-network provider.

Breastfeeding Benefits

Most Marketplace health insurance plans are required to cover breastfeeding support, including equipment and counseling, for pregnant and nursing women. This coverage extends to the entire duration of breastfeeding and includes support both before and after birth. This requirement applies to all Marketplace plans and other health insurance plans, except for grandfathered plans.

Coverage for Breast Pumps:

Your health insurance plan must cover the cost of a breast pump, which can be either a rental or a new one that you keep. Coverage specifics may include whether the pump is manual or electric, the duration of the rental, and when you will receive it (before or after birth). Your plan will follow guidelines set by your doctor, but ultimately, you and your doctor will decide on the best option for you.

Doctor’s Recommendations:

Insurance plans typically adhere to your doctor’s recommendations regarding what’s medically appropriate for breastfeeding. Some plans may require pre-authorization from your doctor. It's important to discuss with your doctor what this means for you and how it might affect your coverage.

For any questions about breastfeeding benefits, contact your insurance plan directly.

Mental Health & Substance Abuse Coverage

All Marketplace health plans are required to cover mental health and substance abuse services as essential health benefits. This ensures comprehensive support for mental and behavioral health needs.

Coverage Includes:

• Behavioral Health Treatment: Services such as psychotherapy and counseling.
• Inpatient Services: Mental and behavioral health services provided in a hospital or other inpatient setting.
• Substance Use Disorder Treatment: Coverage for the treatment of substance use disorders, commonly known as substance abuse.

Key Points to Know:

• Pre-Existing Conditions: Marketplace plans cannot deny coverage or charge higher premiums based on pre-existing mental health or substance use conditions. Coverage for these conditions begins as soon as your plan starts.

• No Spending Limits: Marketplace plans are prohibited from placing yearly or lifetime dollar limits on coverage for essential health benefits, including mental health and substance use services.

Parity Protections:

Marketplace plans must ensure "parity" between mental health and substance abuse benefits and medical and surgical benefits. This means:

• Financial Parity: Deductibles, copayments, coinsurance, and out-of-pocket limits for mental health and substance abuse services must be comparable to those for medical and surgical services.
• Treatment Parity: The number of covered days or visits for mental health and substance abuse services cannot be more restrictive than for medical and surgical services.
• Care Management Parity: Requirements for treatment authorization and other care management practices cannot be more restrictive for mental health and substance abuse services than for medical and surgical services.