Insurance Matters: What does Marketplace health insurance cover?

Amira Wazir

By Amira Wazeer

Starting Jan. 1, 2014, all insurance plans that are certified by the Health Insurance Marketplace provide essential health benefits, follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meet other requirements.

You will need a qualifying health plan known as minimum essential coverage by March 31, 2014 to avoid paying a penalty fee in 2014.

The essential health benefits include at least the following items and services:

Ambulatory patient services (outpatient care you get without being admitted to a hospital)

Emergency services

Hospitalization (such as surgery)

Maternity and newborn care (care before and after your baby is born)

Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)

Prescription drugs

Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

Laboratory services

zero co-pay Preventive and wellness services and chronic disease management

Pediatric services

Essential health benefits are minimum requirements for all plans in the Marketplace however plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace. Luckily most common types of health insurance count as minimum essential coverage as well.

Minimum essential coverage includes the following:

Employer-sponsored coverage (including COBRA coverage and retiree coverage)

Coverage purchased in the individual market, including a qualified health plan offered by the Health Insurance Marketplace (also known as an Affordable Insurance Exchange)

Medicare Part A coverage and Medicare Advantage plans

Most Medicaid coverage

Children's Health Insurance Program (CHIP) coverage

Certain types of veterans health coverage administered by the Veterans Administration


Coverage provided to Peace Corps volunteers

Coverage under the Non-appropriated Fund Health Benefit Program

Refugee Medical Assistance supported by the Administration for Children and Families

Minimum essential coverage does not include coverage providing only limited benefits, such as coverage only for vision care or dental care, and Medicaid covering only certain benefits such as family planning, workers' compensation, or disability policies. Questions call the Marketplace at 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325)

All insurance plans purchased by February 15, if approved will be effective March 1st, 2014. Plans purchased by March 15th will be effective April 1st. The deadline to purchase plans will be March 31st 2014. You must have a valid health care plan at least nine months to avoid paying a penalty.

Amira Wazeer is a state licensed and federally certified insurance agent with over 14 years experience.  She specializes in Medicare, Affordable healthcare plans and Janazza (final expense) insurance. Consultations are free. Need a speaker at your upcoming events or have Questions and comments contact


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