Essential health benefits: what every ACA plan covers
The ten categories of care every Connect for Health Colorado plan must cover, what "no annual or lifetime limit" really means, and what is usually not included.
Every individual and small-group health plan sold under the Affordable Care Act, on or off Connect for Health Colorado, must cover ten categories of essential health benefits: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use services, prescription drugs, rehabilitative and habilitative services, lab work, preventive and wellness care with chronic disease management, and pediatric care including children's dental and vision. Plans cannot put a yearly or lifetime dollar cap on these benefits. Plans can add more, and the details (which drugs, which doctors, how many visits) vary from plan to plan, which is why comparing plans side by side still matters.
The ten categories, in plain English
| Category | What it means for you |
|---|---|
| Ambulatory patient services | Doctor visits and outpatient care when you are not admitted to a hospital |
| Emergency services | Emergency room care, including at an out-of-network hospital |
| Hospitalization | Inpatient stays, including surgery |
| Maternity and newborn care | Care before, during and after birth |
| Mental health and substance use disorder services | Counseling, psychotherapy and behavioral health treatment |
| Prescription drugs | At least the drugs on the plan's list, which varies by plan |
| Rehabilitative and habilitative services and devices | Therapy and devices to regain or build skills after injury or for a disability or chronic condition |
| Laboratory services | Blood work and other tests |
| Preventive and wellness services and chronic disease management | Screenings, vaccines and ongoing care for conditions like diabetes |
| Pediatric services, including oral and vision care | Children's care, with dental and vision for kids |
No annual or lifetime dollar limits
Before the ACA, a serious illness could exhaust a policy's lifetime maximum. Now plans cannot put a dollar limit on essential health benefits, and every plan has an out-of-pocket maximum that caps what you pay for covered in-network care in a year. HealthCare.gov lists the federal ceiling as $10,600 for an individual and $21,200 for a family in 2026, rising to $12,000 and $24,000 in 2027. Many plans set their own maximum lower.
Limits on the number of visits are still allowed for some services, such as physical therapy, as long as they meet state and federal rules. Check the plan documents for the specific service you expect to use.
How Colorado decides the details
Federal law names the categories; each state picks a benchmark plan that sets the specific services inside them. Colorado's Division of Insurance maintains the state's benchmark plan and publishes it on its website. That is why a plan sold in Colorado may cover services that the same insurer's plan in another state does not.
Colorado Option plans go further in some places. For example, the Division of Insurance requires them to cover certain diabetic supplies at $0.
What is usually not included
- Adult dental and adult vision. Children's dental and vision are essential benefits; adult dental and routine adult eye care are not, so most adults buy them separately (see our dental and vision guides).
- Hearing aids for adults, in most plans.
- Long-term custodial care, such as help with bathing and dressing at home or in a facility.
- Cosmetic procedures and services the plan does not consider medically necessary.
- Care received outside the U.S., beyond emergencies, under many plans.
Plans that do not have to cover them
Short-term medical plans, fixed indemnity plans, critical illness policies and health care sharing ministries are not ACA plans and do not have to cover the essential health benefits. Some of them can be sensible add-ons, but none of them is a replacement for a full ACA plan for most families. If you are offered a low price for something that skips maternity, mental health or prescriptions, that is the reason.
How to check a plan before you buy
- Open the plan's Summary of Benefits and Coverage and find the services you expect to use.
- Search your prescriptions on the plan's drug list and note the tier.
- Confirm your doctors and your preferred hospital are in network, by name and location.
- Look at the out-of-pocket maximum: it is the most you would pay for covered in-network care in a bad year.
The bottom line
Essential health benefits are the floor every ACA plan stands on, but plans still differ on drugs, doctors and costs. If you would like me to line up a few Connect for Health Colorado plans against your own doctors and prescriptions, send Lisa a message or call (303) 887-8584.
Want to go through this with someone?
Lisa Asmussen at our Brighton office will go through your doctors, your prescriptions and your real numbers, and explain plainly what we found. Take the Stress Out of Medicare
Sources
- HealthCare.gov: What Marketplace health insurance plans cover, HealthCare.gov (CMS)
- HealthCare.gov: Out-of-pocket maximum limit, HealthCare.gov (CMS)
- Colorado Division of Insurance: Colorado Option, Colorado Division of Insurance
Please note: Headwaters Health and Wealth is not affiliated with, endorsed by, or operating on behalf of Connect for Health Colorado, HealthCare.gov, the Health Insurance Marketplace, or any federal or state government agency. Plan availability, premiums and advance premium tax credits are set by the carriers and the Marketplace.