Vermont Life, Accident & Health (LAH) Insurance Practice Exam

“Essential health benefits” refers to a specific set of health care service categories mandated by the Affordable Care Act (ACA) that must be included in certain health insurance plans. These benefits are designed to ensure that individuals have access to a comprehensive range of health care services, thereby promoting overall health and well-being.

The ACA established ten categories of essential health benefits, which include services such as outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services, and pediatric services. By requiring that these essential health benefits are covered, the ACA aims to improve access to necessary health services for individuals and families, ensuring that they are protected against high medical costs and can receive adequate care.

In contrast, optional benefits that can be added to health insurance plans are not mandated and can vary widely between different policies and providers. The maximum amount an insurance company will pay for a service is defined by policy limits and is not related to the essential health benefits framework. Benefits unique to high-deductible health plans may include features like lower premiums or health savings accounts but do not specifically pertain to the essential health benefits required by the ACA.