Coverage & Benefits
By law, every health insurance plan has to cover some important basics — comprehensive preventive care, prescription drug benefits, emergency services, maternity care and much more.
Essential Health Benefits (EHB)Essential Health Benefits are a comprehensive package of services that all individual and small group health plans must offer. The basic idea is that health insurance should be about making, or keeping, people healthier. As a result, every plan covers the essentials, like an annual physical, prescriptions or an emergency ambulance ride.
Your Essential Health Benefits fall into these 10 categories:
Ambulatory patient services
Preventive and wellness services and chronic disease management
Wellmark's Affordable Care Act (ACA) Preventive Services List PDF File outlines what services are considered preventive for non-grandfathered, under 65 members.
Maternity and newborn care
Mental health and substance-use disorder services, including behavioral health
Rehabilitative and habilitative services and devices
Pediatric services, including dental and vision care
Wellmark does not deny coverage — or charge more — based on health status. Period. Pre-existing conditions are not a factor in your ability to purchase a policy, nor will they affect the quality of care. You’ll know you can get the care you need when you need it.
Summary of Benefits and Coverage (SBC) and Coverage Manuals
A Summary of Benefits and Coverage (SBC) is required by the Affordable Care Act and outlines your plan’s benefits and coverage, plus other unique features like cost-sharing information and coverage limits or exceptions.
A Coverage Manual contains information about your specific medical and prescription benefits. This includes health benefits, costs, limitations and exceptions and network provider information.
Try using the Uniform Glossary of Benefits while looking through your coverage documents because most people don’t use words like "coinsurance" and "in-network" in their everyday lives. With simple, concise definitions, the glossary makes it easier to understand common health insurance terms.