Depending on the scope of coverage, health care plans often pay for part or all of the cost of the following types of services:

  • Standard services such as doctor’s office visits; surgery; hospital care; physical therapy; mental health and substance abuse treatment.
  • Prescription drugs.
  • Preventive and diagnostic services such as physical exams; immunizations; annual gynecological (well-woman) exams; cancer screening (Pap tests, mammograms, prostate exams, and so on); x-rays; laboratory tests; second opinions for surgery.
  • Wellness-related services such as programs to help you stop smoking; weight-loss programs; stress-control courses; discounts at fitness facilities; health-related information via the Internet.
  • Emergency care. Generally speaking, your situation is an emergency if you expect the following to happen if you do not seek care:
    • You would jeopardize your health or your child’s health.
    • If you were pregnant, the health of your unborn child would be in jeopardy.
    • You would have serious impairment of bodily functions.

On the flip side, even comprehensive medical plans typically do not cover certain kinds of services. Each plan includes a list of such non-covered services, described as “exclusions.” These typically are:

  • Cosmetic procedures and surgery (unless to repair damage from an injury or illness).
  • Custodial or long term care.
  • Experimental treatments.
  • Hearing aids.
  • Over-the-counter drugs (such as aspirin).
  • Procedures that aren’t medically necessary.
  • Work-related injuries or illnesses (these would be covered under workers’ compensation coverage).

Once you have selected an insurance carrier and signed a contract, the carrier is obliged to provide all covered employees with a legal document called the Evidence of Coverage (EOC) that describes the benefits covered and the enrollee’s rights under the plan. Encourage your employees to read this document and use it as a reference to help in understanding their coverage.

Some benefits are required by various laws. The Affordable Care Act established broad benefit categories of typical employer coverage, called essential health benefits (EHBs). These include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services (including oral and vision care). This provision is designed to make sure coverage is comprehensive.

To meet this requirement in every state, the rule defines EHBs based on a state-specific benchmark plan, including the largest small group health plan in the state. States would select a benchmark plan from four options identified in the proposed rule, and all plans covering EHBs would be required to offer benefits substantially equal to those of the benchmark plan.

If a state does not make a selection, HHS will select a default benchmark plan. If a benchmark plan is missing any of the 10 categories of benefits, the proposed rule requires the state or HHS to supplement the benchmark plan in that category.