Under the Affordable Care Act, every health insurance plan sold on the marketplace must cover 10 essential health benefits. Understanding what's covered (and what isn't) is the difference between a smart plan choice and an expensive surprise.
The 10 Essential Health Benefits (ACA-Required)
- Ambulatory patient services — outpatient care: doctor visits, urgent care, surgery centers
- Emergency services — ER visits, ambulance (cannot require referral or pre-authorization)
- Hospitalization — inpatient stays, surgery, anesthesia
- Maternity & newborn care — prenatal, delivery, postpartum, newborn baby's first month
- Mental health & substance use disorder services — therapy, counseling, addiction treatment, inpatient psychiatric care
- Prescription drugs — at least one drug from each major therapeutic category
- Rehabilitative & habilitative services & devices — physical therapy, occupational therapy, speech therapy
- Laboratory services — blood work, biopsies, diagnostic testing
- Preventive & wellness services — annual checkups, vaccines, screenings — 100% free, no deductible
- Pediatric services — including dental and vision care for kids
Free Preventive Services (No Deductible)
This is the best feature of ACA plans. The following are 100% free — even before you've paid a penny toward your deductible:
- Annual physicals/wellness visits
- All recommended vaccines (flu, COVID, HPV, shingles, etc.)
- Cancer screenings: mammograms, colonoscopies, skin checks, cervical screenings
- Cholesterol, diabetes, blood pressure screenings
- Contraception and family planning
- Prenatal care and breastfeeding support
- Well-child visits, immunizations, hearing/vision screenings for kids
- Depression and substance abuse screenings
- Tobacco cessation programs
What's NOT Covered (Even on the Best Plans)
- Adult dental and vision (kids covered; adults need separate plans)
- Cosmetic procedures (Botox, plastic surgery, teeth whitening)
- Long-term care (nursing homes — Medicaid or LTC insurance required)
- Weight loss surgery (varies by plan and state)
- Most fertility treatments (IVF varies; some states mandate coverage)
- Alternative therapies (acupuncture, naturopathy, massage — limited)
- Experimental treatments
- Coverage outside the US (limited emergency only)
How to Find Out Exactly What YOUR Plan Covers
Three documents to read:
- Summary of Benefits and Coverage (SBC): Standardized 4-page document. Every plan has one. Lists copays and coverage.
- Drug Formulary: The full list of covered prescription drugs and their tier (cost level). Always check before enrolling if you take regular medications.
- Provider Directory: The list of in-network doctors and hospitals. Check that YOUR doctors are in-network.
Network Tiers Explained
- In-network: Doctors and hospitals that have contracts with your insurance. Lowest cost.
- Out-of-network: No contract. You pay much more — sometimes the entire bill.
- Out-of-network emergencies: Under federal law, you pay in-network rates for true emergencies, even at out-of-network hospitals.
Important: "Covered" ≠ "Free"
"Covered" means the service counts toward your deductible and out-of-pocket max. You may still pay a copay or coinsurance. The only services that are truly free regardless of deductible are the preventive services listed above.
Have specific medical needs? Our licensed agents will check that YOUR doctors and prescriptions are covered before you enroll. Get a custom plan match →