Essential Health Benefits
All Marketplace plans must cover ten essential health benefits in the following categories:
- Ambulatory (outpatient) services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Essential health benefits are covered, but may be subject to the health plan's deductibles, copayments, and coinsurance.
Preventive services
Preventive and wellness services are typically covered with no copayments or coinsurance before you meet your plan's deductible, if they are ordered by your doctor and you're getting the services from an in-network provider or facility.
Your health insurance company can't limit sex-specific recommended preventive services based on your sex assigned at birth, gender identity, or recorded gender — for example, a transgender man who has residual breast tissue or an intact cervix getting a mammogram or pap smear. Learn more about gender-affirming care below.
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
- Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
- Lead screening for children at risk of exposure
- Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Vision screening for all children
- Well-baby and well-child visits
- Abdominal aortic aneurysm one-time screening for adults of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Bone density screening for all people over age 65 or people age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for people at higher risk
- Breast cancer mammography screenings
- Every 2 years for people 50 and over
- As recommended by a provider for adults 40 to 49 or people at higher risk for breast cancer
- Breast cancer chemoprevention counseling for people at higher risk
- Cervical cancer screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Domestic and interpersonal violence screening and counseling for all people
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Folic acid supplements for people who may become pregnant
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they're heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Statin preventive medication for adults 40 to 75 at high risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
- Urinary tract or other infection screening
- Urinary incontinence screening yearly
- Wellness visits (sometimes called well-woman visits) to get recommended services
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for people who are pregnant and nursing
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for people with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers."
- Diabetes screening for people with a history of gestational diabetes who aren't currently pregnant and who haven't been diagnosed with type 2 diabetes before
- Folic acid supplements for people who may become pregnant
- Gestational diabetes screening for people 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Hepatitis B screening for pregnant people at their first prenatal visit
- Post-partum depression screening for birth parent at well-baby visits
- Preeclampsia prevention and screening for pregnant people with high blood pressure
- Rh incompatibility screening for all pregnant people and follow-up testing for anyone at higher risk
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for people with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers."
- Chlamydia infection screening for younger people and other people at higher risk
- Gonorrhea screening for all people at higher risk
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- Pap test (also called a Pap smear) for adults age 21 to 65
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative people at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active people
- Syphilis screening
- Wellness visits (sometimes called well-woman visits) to get recommended services
Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Gender Affirming Care
Gender-affirming care is a procedure, service, drug, device or product that a physical or behavioral health care provider prescribes to treat an individual for incongruence between the individual's gender identity and the individual's sex assignment at birth.
In July 2023, House Bill 2002 was signed which changed the services that are covered as GAC. Below are services that are now covered. This is a list of benefits that changed. Contact your health plan if you have questions about covered benefits.
- Hair removal/electrolysis(not only for surgical sites)
- Voice therapy
- Tracheal shaves
- Facial gender confirmation surgery
- Medical tattooing
- Revisions to prior forms of gender-affirming treatment
- Any combination of gender-affirming treatment procedures.
Explore Health plans cover gender-affirming treatment that is medically necessary and follows accepted standards of care. For specific questions about coverage for gender-affirming care in Explore Healthplans, contact your health insurance company.
If you are having trouble accessing gender-affirming care through your health insurance plan, contact an Oregon Division of Financial Regulation consumer advocate at 888-877-4894 (toll-free), email dfr.insurancehelp@dcbs.oregon.gov or file a complaint online.
Oregon-Specific Guaranteed Benefits
In addition to federal health coverage protections, Oregon requires many health plans to cover additional services and benefits.
All health plans available through Explore Health also include coverage for:
- Abortion services
- Acupuncture
- Chiropractic care
Additional Oregon Health Benefits
Many Oregon-regulated health plans also include coverage or protections for:
- Telehealth and virtual care services
- Mental health and substance use treatment
- Reproductive healthcare and contraception
- Gender-affirming care
- Diabetes supplies and education
- Breastfeeding support and equipment
- Certain fertility preservation services
- Tobacco cessation programs
- Hearing aids for qualifying members
- Autism evaluation and treatment services
Oregon also has protections that help improve access to care, including:
- Access to behavioral health services
- Continuity of prescription coverage
- Appeals and external review rights
- Provider network standards
- Cost and coverage transparency
Coverage and eligibility may vary by health plan and employer type. Some self-funded employer plans may not include all Oregon-specific benefits.