The Affordable Care Act (ACA) requires all marketplace plans to cover a set of 10 essential health benefits. These benefits ensure that your insurance provides comprehensive coverage across a range of medical services[38].
The 10 Essential Health Benefits
All ACA plans—whether bronze, silver, gold or platinum—must include coverage for the following categories[39]:
- Emergency services
- Hospitalization (for surgeries and inpatient care)
- Laboratory services
- Mental health and substance use disorder services (including behavioral health treatment such as counseling and psychotherapy)
- Outpatient care
- Pediatric services (including dental and vision care)
- Pregnancy, maternity and newborn services
- Prescription medications
- Preventive care, wellness services and chronic disease management
- Rehabilitative and habilitative services and devices to help people gain or recover functions after an injury or disability
Marketplace plans must also offer dental coverage for children; adults can often purchase dental coverage separately[40].
Preventive Care Without Cost Sharing
Preventive services are a key part of the essential health benefits. When you receive preventive care from an in‑network provider, you typically do not pay toward your deductible or any copay/coinsurance[41]. Examples of preventive services include:
Children’s Preventive Services[42]
- Autism screening at 18 months and age 2
- Fluoride varnish and lead screening
- Hearing screening for newborns
- Obesity screening and counseling
- Vision screening and well‑child visits
Adult Preventive Services[43]
- Colorectal cancer screening for adults ages 45–75
- Lung cancer screening for high‑risk adults ages 50–80
- One‑time abdominal aortic aneurysm screening for men of certain ages who have smoked
- Statin medications for adults ages 40–75 at high risk of heart disease
Women’s Preventive Services[44]
- Birth control services, including contraceptives, sterilization and counseling
- Bone‑density screening for women 65 and older (or younger women after menopause)
- Genetic counseling and testing (e.g., BRCA) for women with a family history of breast cancer
- Folic acid supplements for women who may become pregnant
- Maternal depression screening during well‑baby visits
- Screening mammograms and well‑woman visits
Out‑of‑Pocket Costs and Metal Levels
While preventive services are covered with no cost sharing, you will pay premiums and cost‑sharing for other services. Premium tax credits help reduce these costs for households within certain income limits[45]. Plans come in metal tiers (bronze through platinum) that reflect how you and the insurer share costs. Bronze plans have lower premiums but higher deductibles, while platinum plans have higher premiums and lower out‑of‑pocket costs.