What Essential Health Benefits Must All ACA Plans Provide?

The Affordable Care Act (ACA), a 2010 comprehensive health-reform law commonly known as Obamacare, has three main goals:

1. Make affordable health insurance available to more people

2. Expand the Medicaid program

3. Support innovation in medical care delivery that reduces costs

ACA health plans are sold through a national marketplace. Though, the District of Columbia and certain states have their own marketplaces. All health plans sold through ACA marketplaces must include coverage for 10 essential health benefits and offer dental coverage for children (though you aren't required to purchase dental coverage).

What are essential health benefits?

There are 10 essential health benefits that all ACA plans must cover:

1. Emergency services

2. Hospitalization (for surgeries and inpatient care)

3. Laboratory services

4. Mental health and substance use disorder services (including behavioral health treatment such as counseling and psychotherapy)

5. Outpatient care

6. Pediatric services (including oral and vision care)

7. Pregnancy, maternity, and newborn services (including prenatal, childbirth, and postnatal care)

8. Prescription medications

9. Preventive care, wellness services, and chronic disease management

10. Rehabilitative and habilitative services and devices (to help people with an injury, disability, or chronic condition gain or recover skills)

What preventive health services fall under essential health benefits?

One category of essential health benefits that applies to almost everyone is preventive care. If you have an ACA plan, you can access preventive health services such as vaccinations and screenings without paying out-of-pocket costs. That means you do not pay toward your deductible and are not charged a copayment or coinsurance when you receive routine preventive care from a provider in your plan’s network. 

EXPERT PICKS: WHAT TO READ NEXT

• You may qualify for a premium tax credit. Find out if you’re eligible for a premium tax credit to help you pay for Affordable Care Act (ACA) coverage.

• When to enroll in coverage: Most people sign up or renew their ACA plans during open enrollment in the fall. But you may also qualify for a special enrollment period.

• A more detailed list of benefits: Learn about how to use your summary of benefits and coverage to find out what your plan will pay for and more.

Preventive care benefits vary for children, adults, and women, specifically. For instance, there are 29 preventive care benefits for children, including:

• Autism screening at 18 months and 2 years old

• Fluoride varnish

• Lead screening for children at risk of exposure

• Obesity screening and counseling

• Routine depression screening beginning at age 12

• Vision screening

• Well-baby and well-child visits

There are 22 preventive care benefits for adults, including:

• Colorectal cancer screening for adults age 45 to 75

• Lung cancer screening for adults age 50 to 80 who are high risk (heavy smokers and those who quit in the past 15 years)

• One-time abdominal aortic aneurysm screening for men of certain ages who have smoked

• Statin-preventive medication for adults age 40 to 75 at high risk of heart attack or stroke

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There are another 27 preventive care benefits specifically for women, including:

• Birth control services, such as contraceptives, sterilization, and patient education

• Bone-density screening for women age 65 and older (and those 64 and younger who have gone through menopause)

• Breast cancer genetic test counseling (BRCA) for women at higher risk because of family history

• Breast cancer mammography screenings

• Folic acid supplements for women who may become pregnant

• Maternal depression screening for mothers at well-baby visits

• Well-woman visits

How much do you pay out of pocket for essential health benefits?

ACA health insurance plans have monthly premiums and other out-of-pocket costs related to care. In the last few years, the American Rescue Plan Act of 2021 and the Inflation Reduction Act of 2022 have provided new financial assistance for ACA premiums. These laws are intended to make ACA coverage more affordable than ever by providing premium tax credits, or premium subsidies, to qualifying enrollees.

In 2024, the Centers for Medicare & Medicaid Services estimated that 4 out of 5 enrollees would be able to find a plan for $10 or less per month for the 2025 plan year because of subsidies. But some people may be able to lower their premiums to $0 a month.

Beyond your monthly premium, you will likely have to pay out-of-pocket costs when you receive care that isn’t considered preventive. You may also be charged if you receive preventive care from an out-of-network healthcare professional. 

These are the types of out-of-pocket costs you are responsible for with an ACA plan:

• Deductible: This is what you will spend before your plan will pay for services other than preventive health services. You can also access routine in-network care, such as checkups and screenings, without paying toward your deductible or anything else out of pocket.

• Copayments and coinsurance: After you meet your deductible, you may be charged a copayment or coinsurance when you access care. A copayment, or copay, is a fixed amount you pay for a service. Coinsurance is a percentage of the cost of a covered health service that you’re responsible for. 

• Out-of-pocket maximum: Also known as the out-of-pocket limit, this is the maximum amount you’re allowed to pay for covered services in a plan year. If your deductible, copayments, and coinsurance reach this amount, your plan pays 100% of the costs of covered services for the rest of the year. In 2025, the out-of-pocket maximum is $9,200 for an individual and $18,400 for a family.

What is not covered under the ACA’s essential health benefits?

Essential health benefits do not include certain services, such as:

• Dental care for adults, though some plans may offer this benefit

• Vision care for adults, though some plans may offer this benefit

• Long-term nursing home care

• Vasectomies

Do large employers have to cover essential health benefits?

Applicable large employers must offer affordable health insurance with minimum essential coverage to their employees (and their employees’ dependents). Under the IRS definition, an applicable large employer had at least 50 full-time employees (including full-time equivalent employees) on average during the previous year. 

If the health insurance offered is not considered affordable, an employer may have to pay a fine to the IRS. This employer shared responsibility is sometimes called the “employer mandate.”

How does the coverage provided for essential health benefits change from plan to plan?

As mentioned, all ACA plans must offer coverage for the 10 essential health benefits. This is true for all metal tiers (platinum, gold, silver, and bronze) as well as all plan types, including preferred provider organization (PPO) and health maintenance organization (HMO) plans. 

Coverage for essential health benefits is also included in catastrophic health plans, which are for people who simply want financial protection in the case of serious illness. These plans also cover preventive health services before the deductible is met. Catastrophic plan premiums are very low, but the deductibles are very high. In 2025, ACA catastrophic health plans have an annual deductible of $9,200 for individuals.

Between states — and sometimes within states — there can be slight differences in the essential health benefits covered by plans. Carefully check the coverage details for any plan you are considering to make the best choice for you and your family.

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Written by:

Monique M. Johnson

Monique M. Johnson is a freelance writer based in Boston. Her work has been featured in Real Simple, Patch.com, and Today.com.

Edited by:

Cindy George, MPH

Cindy George is the senior personal finance editor at GoodRx. She is an endlessly curious health journalist and digital storyteller.

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