All plans available through the Marketplace must cover the services below. For each service, the health insurance company must pay for at least 60 percent of the costs for the covered services. There are 10 essential health benefits included in all plans, with some expansions in Oregon (noted below).
Covered essential health benefits
- Ambulatory patient services, which is any health care you can get without staying in a hospital, such as in a doctor's office, clinic, outpatient surgical center, emergency room, and outpatient hospital department. In Oregon, this includes mammograms.
- Emergency services, including ambulance transport and air ambulance.
- Hospitalization.
- Pregnancy, maternity, and newborn care (pre and post birth). In Oregon, this includes pregnancy and childbirth services and breastfeeding support.
- Mental health and substance use disorder services. In Oregon, this includes treatment of chemical dependency and mental or nervous conditions, and tobacco cessation programs, including counseling, education, and medical treatment.
- Prescription drugs. In Oregon, this includes contraceptives and oral anticancer medications. It also prohibits excluding a particular drug coverage solely because it is not FDA approved for a medical condition.
- Rehabilitative and habilitative services and devices. In Oregon, this includes maxillofacial prosthetic services, prosthetic and orthotic devices, and hearing aids for children and dependents (18 and younger; ages 19 to 26 only if enrolled in accredited higher education).
- Laboratory services.
- Pediatric services, including oral and vision care. In Oregon, this includes speech therapy and occupational and physical therapy, for children younger than 18 with pervasive developmental disorder.
Preventive and wellness services
In addition, all health plans must include the following with zero cost-sharing (no out-of-pocket costs) to the patient even before you meet your deductible, as long as a doctor orders the services and an in-network provider or facility provides them:
- Preventive and wellness services and chronic disease management. In Oregon, this includes breast examinations, human papillomavirus vaccine (HPV) (women only – ages 11 to 26), pelvic and Pap smear examinations, nonprescription elemental enteral formula for the treatment of severe intestinal malabsorption (for both inherited and noninherited metabolic disorders), mastectomy-related services, and coverage to treat traumatic brain injuries (both inpatient and outpatient services).
This is not an exhaustive list of all covered services. Contact your health plan to verify how it will categorize or cover a particular service.