All ACA-compliant health care insurance plans in Wisconsin offer the same set of “essential health benefits.” ACA-compliant (also known as qualified) plans are those that meet the requirements of the Affordable Care Act (ACA) and can be sold in the Health Insurance Marketplace. It is important to note that ACA-compliant health insurance only covers these benefits when delivered by an in-network provider. If you get health services from out-of-network providers (except in an emergency), you may have to pay some or all of the cost.
- Ambulatory Patient Services (outpatient care) – Health care services you get outside of a hospital. This includes visits to your doctor, a clinic, outpatient surgery centers, home health services or hospice care
- Emergency Services (trips to the emergency room) – Care you get for conditions that might lead to serious disability or death if not treated immediately. Your health care insurance plan will cover emergency care out-of-network. You also do not need prior authorization. However, if you stay in an out-of-network hospital after an emergency, your health insurance won’t cover everything. You may be charged the difference between what an in-network hospital would charge and what the out-of-network hospital actually cost
- Hospitalization (inpatient care) – This is the care you get from doctors, nurses and other hospital staff when you are in the hospital. It includes certain lab and other tests, and the medications you get in the hospital. It also covers room and board. This coverage may also include surgeries, transplants and care received in a skilled nursing facility
- Maternity and Newborn Care – This covers many services women need while they are pregnant (also known as prenatal care). It includes labor, delivery and post-delivery. Health care insurance plans also cover care for newborns
- Mental and behavioral health services – These services include inpatient, outpatient, intermediate and transitional care. They are covered when used to evaluate, diagnose and treat a mental health condition or substance abuse disorder. Treatments covered include psychotherapy, counseling and crisis intervention
- Prescription drugs – Health insurance covers medications prescribed by a doctor. At least one drug must be covered for each category and classification of federally approved drugs. For example, “anti-infectives” is a category and “penicillin” is a classification within that category. Health care insurance plans limit drugs they will cover. Typically, generic versions of drugs are covered if they are available
- Rehabilitative and habilitative services and devices – These services help either recover skills or develop skills. For example, speech therapy after a stroke is rehabilitative (recovery). Speech therapy for children learning to speak is habilitative (development). Health care insurance plans may also cover certain devices or tools needed for the rehabilitation or habilitation
- Laboratory services –Tests that help diagnose an injury, illness or condition are generally covered by health care insurance coverage. This includes tests that are used to check the effectiveness of a particular treatment
- Preventive services, wellness services and chronic disease treatment – Certain types of preventive care such as physicals, immunizations and screenings are covered. Many preventive health services are offered at no out-of-pocket cost, even for those who have not reached their deductible. Also, certain kinds of care for chronic conditions, such as asthma and diabetes, are generally included in health care coverage.
- Pediatric services –Medical care of infants and children, including preventive services, is typically covered by health care insurance providers. Preventive services such as well-child visits and recommended vaccines and immunizations are covered, often at no out-of-pocket cost. Health insurance usually includes certain dental and vision care for children younger than 19 years of age.
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