Coverage Basics

What is Covered

Today, there is a wide range of health insurance policies offering different benefits and access to different doctors, hospitals or other health care providers. Starting in 2014, all health insurance plans will share some common characteristics. The Affordable Care Act now requires that all qualified health plans must cover the costs of certain health care services, known as Essential Health Benefits. These benefits fit into the following 10 categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services
  • Chronic disease management
  • Pediatric services, including dental and vision care

Preventative and wellness services for adults include:

  • Immunizations and vaccines
  • Nutrition and diet counseling
  • Screening for cholesterol
  • Screening for cancer
  • Screening for diabetes
  • Screening for depression
  • Screening for STDs and HIV
  • Tobacco cessation treatment

Specific prevention and wellness services for women include:
The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.

  • Anemia screening on a routine basis for pregnant women
  • Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  • Breast Cancer Chemoprevention counseling for women at higher risk
  • *Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women
  • Cervical Cancer screening for sexually active women
  • *Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs
  • *Domestic and interpersonal violence screening and counseling for all women
  • *Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
  • *Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women
  • *Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older
  • Osteoporosis screening for women over age 60 depending on risk factors
  • *Sexually Transmitted Infections (STI) counseling for sexually active women
  • *Well-woman visits to obtain recommended preventive services

Learn more about Affordable Care Act Rules on Expanding Access to Preventive Services for Women.

Specific prevention and wellness services for children include:

  • Alcohol and Drug Use assessments for adolescents
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children of all ages
  • Blood Pressure screening for children
  • Congenital Hypothyroidism screening for newborns
  • Depression screening for adolescents
  • Developmental screening for children under age 3, and surveillance throughout childhood
  • Fluoride Chemoprevention supplements for children without fluoride in their water source
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns
  • HIV screening for adolescents at higher risk
  • Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary and include:
     o  Diphtheria, Tetanus, Pertussis
     o  Haemophilus influenzae type b
     o  Hepatitis A
     o  Hepatitis B
     o  Human Papillomavirus
     o  Inactivated Poliovirus
     o  Influenza (Flu Shot)
     o  Measles, Mumps, Rubella
     o  Meningococcal
     o  Pneumococcal
     o  Rotavirus
     o  Varicella

Learn more about immunizations and see the latest vaccine schedules.

  • Lead screening for children at risk of exposure
  • Obesity screening and counseling
  • Oral Health risk assessment for young children
  • Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis
  • Vision screening for all children

For a complete list of covered prevention and wellness services, click here.