The 10 Essential Health Benefits: All You Need to Know


Since 2014, the Affordable Care Act (ACA) has mandated that insurance plans cover 10 specific services. This mandatory list of services applies to many individual health plans or plans offered through the small-group marketplace (employers with up to 50 employees). Because these general services have been deemed “essential,” they are known as the 10 Essential Health Benefits (EHB).

What Are the 10 Essential Health Benefits?

Here is a list of the 10 essential health benefits and what they mean.

1. Prescription Drugs
The federal government has categorized approved prescription drugs. One from each category must be covered.

2. Pediatric Services

This includes dental care, vision care, well-child visits, vaccinations, and immunizations. Dental and vision care must be offered to children through the age of 19 (pediatric oral health services can include two routine dental exams per year; ocular care can include one annual eye exam).

3. Preventive and Wellness Services and Chronic Disease Management

This includes services such as diet counseling, colorectal cancer screening, Type 2 diabetes screenings, and immunization vaccines.

4, Emergency Services

This is a trip to the emergency room where you truly need care as soon as possible. It means that you won’t be penalized if the hospital is out of network.

5. Hospitalization

Treatment you receive in the hospital as part of inpatient care. Plans may limit coverage for extended stay.

6. Mental Health and Addiction Services

This includes services to treat behavioral health, provide counseling, or provide psychotherapy.

7. Pregnancy, Maternity, and Newborn Care

These are services that care for you and your baby before, during, and shortly after giving birth.

8. Ambulatory Patient Services

This is outpatient care you receive without being admitted to the hospital.

9. Laboratory Services

This includes testing to diagnose, to gauge effectiveness, and some preventive screenings.

10. Rehabilitative and Habilitative Services and Devices

These services help you recover if you are injured, have a disability, or have a chronic condition. Services may include physical therapy, occupational therapy, or speech therapy.

Are My Needs Outside of the 10 Essential Health Benefits Covered?

The 10 essential health benefits do not guarantee that your health insurance policy will cover any service within the 10 categories. Even within our list you may notice that only one prescription from every categorized medication must be covered.

For example, you could be prescribed a generic blood pressure medicine called “bumetanide,” but your health insurance only covers “spironolactone,” despite the diuretic differences.

This means that if you want your coverage to apply to the former medication, you would need your doctor to switch your prescription. However, if you find one formula serves your health better than what is covered under your health insurance policy, the entire cost of the prescription would be out-of-pocket.

The 10 essential health benefits were designed to make sure individual and small-group health insurance plans offer you these services. Although they may not fulfill all your needs, they are a sturdy base to make certain that insured adults and dependents are given the opportunity to receive much needed medical care.


On the other hand, a discussion into how Health Insurance in some other part of the world is looked into. We explored an African country Kenya.

A health insurance policy is less popular among people of Kenya as it is considered very expensive as compared to the benefits one gets as a policyholder. But this is not a complete picture. There are a number of hidden benefits which a person gets and only a person who understands the policy completely can utilize those benefits. Basically, under health insurance Kenya, a user is assumed to pay the specified amount of money for the medical expenses and treatment. In reality, a health insurance comes up with additional benefits which we will explain in this article.

What is a health insurance?
A Health Insurance Kenya is the coverage plan that protects you against risks due to a number of medical conditions. This may include serious illness, chronic diseases, physical injuries, disablement or even death. It covers all expenses before and after hospitalization period.

The purpose of health insurance is to protect you and your family by indemnifying for expenses that may arise from unexpected injury, illness or other health risks. Today, medical treatments are so expensive if you want to get treated in a good hospital so you should not contemplate on whether to invest in a health insurance policy or not. Life is completely unpredictable today and you should feel lucky that you have a choice to secure life by getting the financial protection against the major risks to our life.

With several players in the insurance sector, you are at liberty to opt for a policy that is not only pocket-friendly but also fulfilling our requirements. Typically, every insurance company offers a number of plans and based on your pre-existing medical conditions and family health history, you can better that fits your budget and needs.

What does this policy cover?
As a policyholder, the policy extends over a number of situations which are described below:

1. You will go cashless for all the transactions under medical treatment across a network of hospitals under the insurer. In case, the hospital where you were referred for treatment is out of that network, you will be reimbursed for the amount you paid.

2. Amount spent on treatment pre and post hospitalization as well as charges for daily case health services after discharge

3.All the expenditure on maternity and newborn care.

4. Amount spent in laboratories for the medical tests.


Benefits of a Health Insurance Policy

A health insurance is indispensable when it comes to financially safeguarding your family and yourself in case of any eventuality. While the benefits of an insurance policy are many, it is important to compare and opt for one that serves your purpose in particular as against popular market trends.

1. Having a health insurance policy covers you with the consultation fees or visiting a doctor.

2. In case, you are referred to specialists where consultation fee is higher and need to go for monthly checkups, your policy will cover you with all the charges.

3. In the event, you are hospitalized as a result of some serious disease or illness, your insurer will meet all the hospitalization expenses including treatment, laboratory tests, medicine cost, accommodation, catering, laundry services etc.

4. Usually, the insurance companies cover the cost of drugs recommended by the physician. This may include the medicines obtained from hospital’s pharmacy, or from a chemist accredited by the insurance company.

5. A health insurance policy typically covers the costs associated with lab tests recommended by the doctor before starting the treatment or analyzing the problem.

6. Some insurance companies include an ambulance benefit. In this event, the insurance company provides an ambulance to take you to the hospital in case of an emergency.

7. Another one of the many benefits of a health insurance policy lies in the fact that the policy can extend coverage to the insured’s parents/parents-in-law, spouse and children.


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