Under the Affordable Care Act what percentage of preventive care must be covered

Essential health benefits are the medical services that must be covered under any Affordable Care Act (ACA) marketplace plan.

The Affordable Care Act is the 2010 comprehensive health-reform law commonly known as  “Obamacare,” or the ACA. The law has three main goals:

• Make affordable health insurance available to more people.

• Expand the Medicaid program.

• Support innovation in medical care delivery that reduces costs.

ACA health plans are sold on a national marketplace for residents of 33 states. Residents of 17 states and the District of Columbia have their own ACA marketplaces.

All health plans sold on ACA marketplaces must include the 10 essential health benefits as well as dental coverage for children.

How many essential health benefits does the ACA mandate?

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

• Emergency services

• Hospitalization (surgeries and inpatient care)

• Laboratory services

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

• Outpatient care

• Pediatric services (including oral and vision care)

• Pregnancy, maternity, and newborn services (includes prenatal, childbirth, and postnatal care)

• Prescription drugs

• Preventive care, wellness services, and chronic disease management

• Rehabilitative and habilitative services and devices (to help people gain or recover skills after injury as well as amid disability or chronic conditions)

Plans also must provide birth control coverage (with exemptions for plans sponsored by certain religious employers) and breastfeeding coverage.

Coverage under each category can vary slightly by state and within states. The differences may be which services are included and the number of covered visits. Some states require additional coverage in ACA plans beyond essential health benefits. This may include dental and vision coverage for adults.

What preventive health services does the ACA mandate?

One category of essential health benefits that applies to almost everyone is preventive care. 

Under the ACA, preventive health services such as vaccinations and screenings are provided without out-of-pocket cost. That means you do not pay toward your deductible and are not charged a copayment or coinsurance when you receive routine care from a provider in your plan’s network. 

Preventive care benefits vary for children, adults, and women, specifically.

For instance, there are 29 preventive care benefits for children, including:

• Autism screening for children at 18 months and 2 years old

• Depression screening beginning routinely at age 12

• Fluoride varnish

• Lead screening for children at risk of exposure

• Obesity screening and counseling

• Vision screening

• Well-baby and well-child visits

There are 22 preventive care benefits for adults, including:

• Abdominal aortic aneurysm one-time screening for men of certain ages who have ever smoked

• Colorectal cancer screening for adults age 45 to 75

• Lung cancer screening for adults age 50 to 80 at high risk because they are heavy smokers or because they quit in the past 15 years

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

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

• Birth control, such as contraceptives, sterilization, and patient education (excludes health plans sponsored by certain exempt religious employers)

• Folic acid supplements for women who may become pregnant

• Maternal depression screening for mothers at well-baby visits

• Bone-density screening for women age 65 and older, or 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

• Well-woman visits

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

An ACA health insurance plan requires a monthly premium and may have more out-of-pocket costs when you receive care.

The American Rescue Plan Act of 2021 and the Inflation Reduction Act of 2022 provide new financial assistance for ACA premiums in 2023. These savings will make ACA healthcare coverage more affordable than ever. The Centers for Medicare & Medicaid Services (CMS) reports that 4 out of 5 people will be able to find a plan for $10 or less per month.

If you qualify for a premium tax credit — also known as a premium subsidy — this financial help will reduce your monthly bill. Some people may have a $0 premium.

Beyond your monthly premium, you may have expenses when you receive care. These costs are likely if you are not accessing a preventive health service. You may also have out-of-pocket costs if you are not receiving preventive care with a provider in your coverage network. 

When you receive most essential health benefits, you probably will have these out-of-pocket costs:

• Deductible: This is what you will spend before the insurance begins to pay, except for preventive health services. Routine care such as checkups and screenings in your plan’s network are provided without you paying a deductible or anything else out of pocket.

• Copayments and coinsurance: These are payments you may make each time you get a service (excluding preventive health services). A copayment, or copay, is a fixed expense that you pay after meeting your deductible. Coinsurance is a percentage of the cost of a covered health service after you have met your deductible. 

• Out-of-pocket maximum: Also known as the out-of-pocket limit, this is the most you must pay for covered services in a plan year. After your deductible, copayments, and coinsurance reach this amount, all covered services in a plan year are paid 100% by the insurance company. For 2023 marketplace plans, the out-of-pocket maximum is $9,100 for an individual and $18,200 for a family.

Do ACA insurance plans cover other health benefits?

In addition to the essential health benefits, which are a minimum requirement, some plans may offer other benefits for adults, including:

• Dental coverage

• Vision coverage

• Medical management programs (may be offered for conditions such as heavier weight, back pain, and diabetes)

You should carefully compare plans to see what is offered. 

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

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

• Dental coverage for adults, though some plans may offer this as a benefit

• Vision coverage for adults, though some plans may offer this as a benefit

• Long-term nursing-home care

• Vasectomies

Do large employers have to cover essential health benefits?

An employer must offer health insurance with minimum essential coverage to its employees and their dependents if the business is considered an applicable large employer (ALE). Under the Internal Revenue Service definition, an applicable large employer had at least 50 full-time employees (including full-time equivalent employees) on average during the previous year. 

The employer’s minimum essential coverage must be considered “affordable” for employees by the IRS. If the health insurance offered is not considered affordable, the employer might have to make a payment to the agency. This employer shared responsibility is sometimes called the “employer mandate.”

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

All plans within the healthcare marketplace will offer the 10 essential health benefits. This is true for all metal tiers (platinum, gold, silver, and bronze) as well as plan type (such as PPO or HMO). 

Essential health benefits are 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 without meeting a deductible. Catastrophic plan premiums are very low, but deductibles are very high. In 2023, ACA catastrophic health plans will have an annual deductible of $9,100 for individuals.

Between states — and sometimes within states — there can be slight differences in the essential health benefits offered. Carefully check the coverage of each plan you are considering to make the best choice for you and your family.

What should you look for in essential health benefits coverage when choosing an ACA health plan?

Essential health benefits cover health needs from preventive care to emergency services. Choose a plan that provides coverage for the healthcare concerns in your household. For example, if you have diabetes, you might want to choose a plan that offers a medical management program for your condition.

The bottom line

Essential health benefits provide health coverage in 10 categories for people with Affordable Care Act health plans. This minimum standard ensures access to coverage for critical healthcare needs. Specific coverage can vary slightly by state and within states. When choosing your plan, align your health needs with what is offered by carefully reviewing the services that are important to you.

GoodRx Health has strict sourcing policies and relies on primary sources such as medical organizations, governmental agencies, academic institutions, and peer-reviewed scientific journals. Learn more about how we ensure our content is accurate, thorough, and unbiased by reading our editorial guidelines.

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