Understanding Essential Health Benefits Under
The Affordable Care Act

​Health insurance plans must offer 10 Essential Benefits to comply with the Affordable Care Act (ACA). These benefits are guaranteed to anyone, including people with pre-existing conditions who may have been denied coverage in the past.

✔ Ambulatory patient services
✔ Emergency services
✔ Hospitalization
✔ Maternity and newborn care
✔ Mental health and substance abuse services
✔ Prescription drugs
✔ Rehabilitation, habilitation services and devices
✔ Laboratory services
✔ Preventive, wellness and chronic disease management
✔ Pediatric services with oral and vision care

100% Coverage for Preventive Care

Prevention, wellness care, and screenings are 100% covered under Obamacare, including guaranteed acceptance for pre-existing conditions (routinely excluded in the past). Some of the services that fall into this extensive category include women’s health (prenatal care, contraceptives, domestic violence counseling, and disease screenings), healthy-child screenings and immunizations, cancer screenings, behavioral health, and dental/vision coverage for children under 18.

Understanding Metal Tier Plans

The ACA defines qualified coverage under four levels called the Metal Tier plans defined by their percentage of covered benefits and levels of premiums. They all meet the Essential Benefit requirements.

What is Actuarial Value?

The four metal plans (platinum, gold, silver, and bronze) are based on different actuarial values. The actuarial value is the amount of medical expenses paid over the course of a typical year, for an average policyholder. It does not reflect how much the policy would pay for any particular medical bill, but it measures the percentage of expected medical costs a health plan will cover based on the standard population of covered individuals. Metal plans higher actuarial values reflect less cost-sharing across a population. This results in higher premiums associated with that plan level.

The actuarial value of a Silver plan, for example, is 70 percent. Across a standard population, individuals would be responsible for 30 percent of the cost of deductibles and copays, over a typical year.

Young Adults Essentials

Young adults under the age of 30 often opt out of getting health insurance because they are generally in good health and sometimes don’t have employer-based benefits. Under the new law young adults will be required to get coverage, but they do have the option of choosing a less expensive catastrophic plan that includes the essential benefits and preventive services. These plans lower costs by limiting the number of doctor visits they will cover. However, if an individual qualifies for tax credits they will not be allowed to apply them towards a catastrophic plan.

More on Catastrophic Plans

Catastrophic plans cover preventive services at 100%, including three yearly office visits. The deductibles for these plans can be high – hence the term “catastrophic”, since they’re only going to protect you from significant loss due to a substantial medical event. Catastrophic plans are also available to low-income individuals in states with expanded Medicaid.

Because of the higher deductibles associated with these plans, bronze-level plans combined with a health savings account (HSA) may actually offer a better and less expensive option for many young adults. Colohealth Personal Benefits Managers can explain more about catastrophic and fully-insured accident plan options.

How ColoHealth Works to Save You Money

We believe in breaking down the complicated options when it comes to your healthcare, so that you can find the best plan and strategy to meet your needs. Depending on your situation, that might mean a health insurance plan with no lifetime limits; for some it might mean a health insurance plan that qualifies for cost-sharing subsidies that will further lower your costs; and for others who don’t qualify for a subsidy it might be a less expensive non-insurance option, such as joining a healthshare program.

You can learn more about the healthshare plans we recommend on our Colorado Healthshare Plans page.

Call your Colohealth Personal Benefits Manager at (800) 913-6381 or email us at [email protected] to find your best strategies for reducing your costs. Our services are always free!

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