Which of the following is one of the categories of essential health benefits that must be covered by a non-grandfathered individual or small group health plan?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
ACA Sections 1302 and 18022 define essential health benefits by category, and mental health and substance use disorder services, including behavioral health treatment, are on that list, along with ambulatory patient services, emergency services, hospitalization, maternity and newborn care, 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. Adult dental and vision, cosmetic surgery and custodial long-term care are not essential health benefits, which is a common source of consumer complaints after enrollment.
Why the other options are wrong
- A) Custodial long-term care in a nursing facility is not one of the essential health benefit categories and is generally excluded from major medical coverage.
- B) Cosmetic surgery performed purely to improve appearance is not an essential health benefit category.
- C) Only pediatric oral and vision care is an essential health benefit; adult dental and adult vision services are not among the categories defined under ACA Sections 1302 and 18022.
Memory hook
Pediatric yes, adult no, and behavioral health is in.