Understand your benefits

Mental health and substance use

Mental health and addiction benefits cover both inpatient and outpatient care intended to evaluate, diagnose, and treat a mental health issue or substance use disorder. This can include medications, facility stays and behavioral health treatment. Many plans do place an annual limit on therapy sessions and may require a higher copay for behavioral or mental health treatments than they do for other health care services. 

Ambulatory patient services 

This is the most basic and frequent type of benefit used. A typical use of an outpatient care benefit would be walking into a doctor's office, receiving treatment, and walking out. Many outpatient services are received from a family doctor or primary care physician but they also include specialists like cardiologists(heart doctors) and orthopedists (bone doctors).

Understand your benefits 

Pediatric Services 

Benefits include care for all children under 19 and many plans will cover dependents up to age 26. Providers must cover well-child visits, routine annual physical exams, and necessary vaccines and immunizations. Dental and vision care must also be offered and includes two dental exams, an eye exam, and corrective lenses annually. 

Maternity and newborn care

 Under the Affordable Care Act, pregnancy can no longer be counted as a pre-existing condition.Marketplace plans must cover prenatal care like sonograms, delivery services, and postpartum services. Care for newborn babies must be covered as well. 

Health Care Benefits

Rehabilitative and habilitative services

These benefits focus on treatment for recovery from or management of an injury, disability or chronic health condition. Plans cover devices like canes, walkers, and wheelchairs. Treatments covered include physical and occupational therapy, speech-language pathology, andpsychiatric rehabilitation. Plans must provide 30 visits per year for physical therapy, chiropractor services, or occupational therapy.

Emergency services

If you have a sudden onset of serious symptoms(e.g. exhibiting signs of a stroke or heart attack) and go to a hospital emergency room, your costs will be covered without requiring pre-authorization. Your heart attack won't wait for pre-authorization. Your coverage shouldn't have to. Additionally if the hospital or physician is out of coverage you cannot be charged extra. 

Preventive and Wellness Services 

Preventive care benefits also include some chronic disease treatments. Plans cover services like physicals, immunizations, and screenings for certain medical conditions. Many plans will cove screening for cancer, asthma, diabetes, and HIV. 


This is the care you receive from doctors, nurses, and other hospital staff while staying in a hospital. It includes diagnostic tests, medications, and room and board. This also includes transplants, surgeries, and care received in a skilled nursing facility. Your insurer must cover you hospital stay but you may be responsible for a 20 percent or more of the bill if you have not reached your out of pocket limit. 

Laboratory services

Laboratory services are diagnostic tests that a doctor uses to diagnose an illness, inury, or condition. They can also help your doctor understand how well a particular treatment is working. Lab services include blood tests, MRIs and diagnostic imaging, and more. Some lab services that are considered preventive screenings are provided free of charge. 

Prescription Drugs 

This set of benefits refer to the medications a doctor prescribes to treat a condition or illness. This includes things like antibiotics for strep throat and statins for blood pressure. All marketplace plans must cover at least one drug in every category and class of approved drugs to ensure everyone can afford the medication they need.  Drug costs will be counted toward the cap on out-of-pocket medical expenses.