The Affordable Care Act (ACA) defines certain care as essential benefits that must fall under health insurance coverage. These minimum requirements apply to health plans that were not in existence on March 23, 2010. Examples include mental health and substance abuse treatment, maternity and newborn care, and preventive and wellness services (such as a flu shot).
Before the ACA, many plans offered limiting coverage in some areas to keep costs down. The result lead to people paying for health plans for years, only to find out they didn’t have the care they thought they had, or their health problems triggered a dollar limit on spending for a healthcare service and the insurance plan denied care.
Even with the 10 essential benefits defined in the ACA, insurance companies can still put an annual or lifetime dollar limit on spending for some services because they are not considered essential benefits. Health plans can also set limits on the number of times you can receive a certain treatment.
Non-essential benefits differ from health plan to health plan. The best way to know what your health plan covers, doesn’t cover – and where it limits coverage – is to know your health plan’s rules up front. You can find them in the summary of benefits and coverage your health plan sends you.
Examples of non-essential benefits might include:
November 03, 2016
Christopher Nystuen, MD, MBA