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Obamacare 101: Essential Health Benefits


In three weeks, the Texas health insurance marketplace will be open for business. There will be a variety of plans to choose from – the basic bronze and even platinum – but all of them, and many private insurance plans too – will be required to cover certain benefits like checkups starting in 2014. As part of KERA’s series, “Obamacare 101,” we get the breakdown from Stacey Pogue of theCenterfor Public Policy Priorities, an Austin-based nonprofit.

The KERA radio story

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“Essential health benefits are a core set of services that cover 10 broad categories [see below], like hospitalization, doctors’ visits, and prescription drugs,” Pogue says.  These benefits may still be subject to a copay or coinsurance, or you might have to meet your deductible first, Pogue says, “But you’re not going to find fine print later that says you aren’t covered when you’re in the hospital or for an emergency.”

Any plan offered in on the Texas health insurance marketplace must include a standard set of benefits across 10 categories. These are:

  1. Ambulatory patient services (outpatient care you get without being admitted to a hospital, like routine doctor’s office visits)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including vision care.

[More From KERA News: Obamacare 101: Dental Care, Infertility Treatment And Hearing Aids]

Lauren Silverman was the Health, Science & Technology reporter/blogger at KERA News. She was also the primary backup host for KERA’s Think and the statewide newsmagazine  Texas Standard. In 2016, Lauren was recognized as Texas Health Journalist of the Year by the Texas Medical Association. She was part of the Peabody Award-winning team that covered Ebola for NPR in 2014. She also hosted "Surviving Ebola," a special that won Best Long Documentary honors from the Public Radio News Directors Inc. (PRNDI). And she's won a number of regional awards, including an honorable mention for Edward R. Murrow award (for her project “The Broken Hip”), as well as the Texas Veterans Commission’s Excellence in Media Awards in the radio category.