Learn the 10 Essential Health Benefit categories Marketplace plans are required to cover, what “covered” really means, and why plan costs and provider networks still matter.
ACA Marketplace plans must include coverage across these Essential Health Benefit categories. Specific services, limitations and cost-sharing can vary by plan and applicable rules.
Outpatient care received without being admitted to a hospital.
Coverage for qualifying emergency medical services under applicable plan terms and protections.
Covered inpatient hospital services, including applicable surgery and hospital care.
Covered care related to pregnancy, childbirth and newborn health.
Behavioral health and substance use disorder services, including applicable treatment.
Prescription medication coverage according to the plan's formulary and rules.
Services and devices that help people gain, recover or maintain applicable skills and functions.
Covered laboratory testing and related services under applicable plan terms.
Specified preventive services and chronic-disease management benefits under applicable ACA requirements.
Healthcare benefits for children, including applicable oral and vision care.
A health plan may cover a service while still requiring you to pay some portion of the cost. Depending on the service and plan, that can involve a deductible, copayment, coinsurance or another applicable cost-sharing requirement.
Certain qualifying preventive services can receive different cost-sharing treatment when applicable ACA requirements are met.
Your cost and access can depend on whether a doctor, hospital, pharmacy or other healthcare provider participates in your plan's network and on the specific plan rules.
Check whether the physicians and specialists important to you are in-network.
Review the network status of hospitals and healthcare facilities you may prefer or regularly use.
Review the plan's formulary and applicable medication cost-sharing rather than assuming every prescription works the same way.
Understand Plan & Network Types →Marketplace plans share the ACA's required benefit framework, but premiums, deductibles, networks, formularies and other plan details can still differ.
Use the Essential Health Benefit framework as a starting point, then compare how individual plans handle costs, networks and your household priorities.
Learn How to Compare ACA Plans →