The 10 Essential Benefits and Our Plans
All of the individual and family health plans offered on the Health Insurance Marketplace® must cover 10 specific services. These individual and family plans cover these services or benefits because under the Affordable Care Act they are required — or essential — benefits.
The essential benefits include:
- Ambulatory patient services
This includes all outpatient services that you receive without admission to a hospital, such as walking into your primary care provider’s office for a regular visit.
- Emergency services
This service is provided when you go to the emergency room for life-threatening situations or conditions. You cannot be charged extra for an out-of-network emergency visit.
This benefit includes inpatient care such as surgery and overnight stays in the hospital.
- Pregnancy, maternity, and newborn care
Under this benefit, health care coverage is provided both before and after birth.
- Mental health and substance use disorder services
Behavioral health treatment, counseling, and psychotherapy are part of this service.
- Prescription drugs
Under this benefit, all plans must cover at least one drug from every category listed in the U.S.
- Rehabilitative and habilitative services and devices
This benefit provides coverage of services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.
- Laboratory services
This benefit includes testing to diagnose diseases and injuries to determine whether a treatment or service is effective, as well as some preventive screenings.
- Preventive and wellness services and chronic disease management
The goal of this benefit is to get people to see their primary care provider before they get sick. It includes many preventive services covered by your plan at no extra cost.
- Pediatric services
This includes dental care through stand-alone dental plans and vision care for children younger than age 19.
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Levels of Coverage
Under the Affordable Care Act, there are four levels of coverage on the Marketplace Exchange:
The categories have nothing to do with the amount of care or quality of care you receive. The plans in these metal levels differ based on how the plan share the costs of care with the member, which is called actuarial value (AV).
AmeriHealth Caritas Next offers gold, silver, and bronze plans. All of these plans cover the 10 essential benefits.