What an ACA plan covers
By law, every Marketplace plan covers the same 10 categories of essential benefits. What changes between plans is the doctor network and how much you pay out of pocket — not whether a treatment is covered.
The 10 essential health benefit categories
They're set in federal law. No insurer can sell a Marketplace plan that leaves one out.
Ambulatory patient services
Care you get without being admitted: office visits, outpatient surgery, therapies.
Emergency services
The emergency room, with no prior authorisation needed and no penalty for using an out-of-network hospital.
Hospitalization
Inpatient stays, major surgery and the care you receive while admitted.
Pregnancy, maternity and newborn care
Before, during and after birth. An ongoing pregnancy can't be excluded as a pre-existing condition.
Mental health and substance use disorder services
Includes behavioural treatment, psychotherapy and counseling. The law requires parity with medical benefits.
Prescription drugs
Every plan publishes its formulary — the list of drugs it covers and at what cost tier.
Rehabilitative and habilitative services and devices
Physical, occupational and speech therapy; durable medical equipment to recover or develop skills.
Laboratory services
Tests and diagnostic work.
Preventive and wellness services and chronic disease management
Federal preventive services carry no cost sharing when you stay in network.
Pediatric services, including dental and vision
For under-19s. Adult dental and vision coverage isn't part of this category.
Protections that apply to every plan
- No exclusion for pre-existing conditions. Your medical history affects neither your access nor your premium.
- No annual or lifetime caps on essential benefits.
- A ceiling on out-of-pocket costs. Once you reach it in a year, the plan covers 100% of essential in-network services.
- Children covered to age 26 on a parent's plan.
What an ACA plan usually doesn't cover
Worth knowing beforehand, not when the bill arrives:
- Adult dental and vision — bought separately.
- Long-term care (nursing homes, extended home care).
- Cosmetic surgery.
- Care outside the United States, apart from specific plan exceptions.
What you pay for all this coverage depends on your plan tier and the financial help you qualify for. See what it costs and subsidies and tax credits.