Benefits are the health services your insurance pays for. As part of healthcare reform, California law states that there must be a minimum set of benefits in most health insurance policies. These are called Essential Health Benefits or EHBs. Some policies sold prior to January 1, 2014 are "grandfathered" and do not have to cover Essential Health Benefits. Below is the list of the EHB categories.
Essential Health Benefits include:
- Hospital care
- Visits to a primary care doctor and specialists
- Outpatient procedures, like surgery
- Laboratory tests and diagnostic services, like x-rays and mammograms
- Pregnancy and newborn care
- Preventive and routine care, like vaccinations and checkups
- Mental health care
- Emergency and urgent care
- Rehabilitation therapy, such as physical, occupational and speech therapy
- Some home health or nursing home care after a hospital stay
- Prescription drugs
- Substance abuse treatment
- Oral and vision care for children
For more information about California's Essential Health Benefits, you can contact our Consumer Hotline.
Your health insurance offers many benefits. The services your insurance covers must be medically necessary. Sometimes, you and your provider and your insurer may disagree about what is medically necessary. If that happens, help is available. California law provides for an independent review of your case after you have filed an appeal with your insurer. Please see the Department's Independent Medical Review page for more details on your options. You can also call the Department's Consumer Hotline at 1-800-927-4357 (HELP) or get help online.
Preventive Care
Preventive care helps you stay healthy. It also helps doctors catch health problems early. It includes:
- Blood pressure, diabetes, and cholesterol tests
- Birth control
- Cancer screenings
- Routine vaccines
- Regular pediatrician visits
- Vision and hearing screening for children
- Counseling about obesity
The Affordable Care Act requires that these services be provided to you without any out-of-pocket cost to you.
- This means that you do not have a co-pay or co-insurance for the preventive care.
- Even if you have not met your deductible yet, you do not have to pay for the preventive care.
- Grandfathered policies may not need to follow this rule.
Visit the Federal government's Healthcare.gov web site for a complete list of preventive services.
