No Limits on “Essential” Care

small_essential_health_benefitsStarting in 2014, insurance companies can no longer place annual or lifetime limits on how much you can spend on what the law calls “essential care.”  This includes: emergency care, hospitalization, maternity & newborn care, prescription drugs, lab work, preventive care, chronic disease management, and many pediatric services.


  • A factsheet on essential care from the California Department of Managed Health Care
  • A more detailed breakdown on which plans will cover what from
  • Here’s how defines “essential” benefits:

A set of health care service categories that must be covered by certain plans, starting in 2014.

The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories:

  • ambulatory patient services;
  • emergency services;
  • hospitalization;
  • maternity and newborn care;
  • mental health and substance use disorder services, including behavioral health treatment;
  • prescription drugs;
  • rehabilitative and habilitative services and devices;
  • laboratory services;
  • preventive and wellness services and chronic disease management;
  • and pediatric services, including oral and vision care.

Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace, and all Medicaid state plans must cover these services by 2014.