What Does Medical Insurance Typically Cover?
According to the Affordable Care Act (ACA), individual and small group medical insurance plans must include certain types of essential health benefits as well as a specific group of preventive care services available at no cost to the member.* Plans sold on the Health Insurance Marketplace that offer this coverage are called “ACA-compliant" or "qualified health plans”.
The essential health benefits that must be covered by medical insurance plans to be considered an ACA-compliant health plan include at least the following items and services –
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (such as surgery)
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
In Wisconsin, essential health benefits also include chiropractic care, certain kinds of hearing aids, treatment for autism spectrum disorder and more.
What preventive services does medical insurance have to cover?*
The ACA directs medical insurance plans to provide certain preventive services at no cost to the member. These services include screenings such as blood pressure, HIV and diabetes for adults, breast cancer screening for women older than 40, and specific immunizations for children and adults. The list is designed to help find health issues before they become problems. See the list of preventive services.
It is important to note that if you go to the doctor for a no-cost preventive service and other services are provided in the same visit, you will be billed for those services separately based on your health insurance coverage. Learn more.
Do all medical insurances cover essential health benefits?
It is possible to buy a plan that does not cover all essential health benefits. However, all medical insurance available on the Health Insurance Marketplace covers these benefits.
All of Unity’s individual medical insurance plans available to purchase provide essential health benefits, preventive care and much more. Unity members have guaranteed access to the 1,300 doctors and specialists of UW Health and Wisconsin’s #1 hospital** – UW Hospital and Clinics.
*These rules don’t apply to grandfathered plans.
**According to the 2015-2016 edition of the Best Hospitals guide by U.S. News & World Report.