minimum essential coverage

What Does Minimum Essential Coverage Entail?

Minimum Essential Coverage was created when the Affordable Care Act was enacted. Before the Affordable Care Act began, people who already had medical conditions or had used too much medical care in the past were able to be denied coverage by insurers. Minimum Essential Coverage ensures that all ACA-compliant health care plans offer insurance to all enrollees regardless of health status or which plan they select. What exactly does minimum essential coverage entail?

To be considered minimum essential coverage, all health plans must cover ten necessary benefits. The amount of those benefits that they cover depends on the actuarial value. This number is determined by metal tiers, which depend on how much you pay per month. The more you pay the more is covered.

So what are the essential benefits that will be covered under minimum essential coverage?

Every plan must include these necessary benefits to ensure affordable health care for all. This saves people from spending ungodly amounts of money on health care services. These benefits include:

  • Laboratory Services: This includes diagnostic lab tests and preventive screening tests, like diabetes and cholesterol screenings.
  • Emergency Services: Any emergency care at a hospital or a facility out of network is covered with your insurer. 
  • Prescription Drugs: The medications are categorized by tiers, each tier contains at least one drug that your insurance will assists payment for. However, not all medications are within the tier, so similar medications to the ones included will not be covered under insurance.
  • Mental health and substance abuse related services: All plans include some kind of coverage for emotional and psychological well-being. These services include counseling, psychotherapy, mental health inpatient services, and treatment for substance abuse.
  • Maternity and newborn care: All plans include multiple services that care for you and your baby during all stages of your pregnancy, the delivery, and after delivery. 
  • Pediatric Services: For children who are included in your health plan your insurance will cover services that keep them healthy, including oral, vision care, vaccinations, and well-child visits.
  • Rehabilitation and habilitative services and devices: These services and devices that are designed for people with injuries, chronic conditions, and disabilities. It also includes physical, occupational, and speech therapy visits. 
  • Ambulatory patient services: Services included in outpatient care when a medical facility does not keep you the night after a procedure are covered.
  • Preventive/ wellness services and chronic disease management: Any services that assist you in staying healthy are covered by all insurance plans. This includes cancer screenings, annual checkups, and other preventative measures.
  • Hospitalization: If you have to go to the hospital for inpatient care, all plans are required to help with medical bills. This may only be more a certain period of time, but they are required to assist with the cost.

In addition to these 10 essential benefits for each plan, COVID-19 testing is also considered an essential health benefit. You must meet the CDC testing criteria to receive the test. If you live outside of California, New York, and Washington you will be required to pay any deductibles, copay, or coinsurance.

At SBMA, we are committed to providing top-of-the-line ACA compliant solutions to your insurance needs. Contact us for more information.

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