The 10 Essential Benefits and Our Plans

All the health plans offered on the Health Insurance Marketplace must cover 10 specific services. Marketplace insurance plans cover these services or benefits because under the Affordable Care Act they are required — or essential — benefits.

The essential benefits include:

1. Ambulatory patient services
   This includes all outpatient services that you receive without admission to a hospital, such as walking into your primary care provider’s office for a regular visit.
2. Emergency services
   This service is provided when you go to the emergency room for life-threatening situations or conditions. You cannot be charged extra for an out-of-network emergency visit.
3. Hospitalization
   This benefit includes inpatient care such as surgery and overnight stays in the hospital.
4. Pregnancy, maternity, and newborn care
   Under this benefit, health care coverage is provided both before and after birth.
5. Mental health and substance use disorder services
   Behavioral health treatment, counseling, and psychotherapy are part of this service.
6. Prescription drugs
   Under this benefit, all plans must cover at least one drug from every category listed in the U.S.
7. Rehabilitative and habilitative services and devices
   This benefit provides services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.
8. Laboratory services
   This benefit includes testing to diagnose diseases and injuries and to determine whether a treatment or service is effective, as well as some preventive screenings.
9. Preventive and wellness services and chronic disease management
   The goal of this benefit is to get people to see their primary care provider before they get sick. It includes many preventive services covered by your plan at no extra cost.
10. Pediatric services
    This includes dental and vision care for children younger than age 19.

Levels of coverage

Under the Affordable Care Act, there are four levels of coverage for individual and family health plans:

• Bronze
• Silver
• Gold
• Platinum

The metal levels have nothing to do with the amount of care or quality of care you receive. The plans in these metal levels differ based on how the plans share the costs of care with the member, which is called actuarial value (AV).

AmeriHealth Caritas Next offers Bronze, Silver, and Gold plans. All of these plans cover the 10 essential benefits.

Get information on the individual and family health plans we offer, and find a plan that meets your health care needs.