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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

It’s an industry term that includes almost any medical service you can get outside of a hospital. Think regular doctor visits, urgent care, outpatient clinics, etc.

Preventive and wellness services and chronic disease management

This includes physicals, immunizations and health screenings but also treatment for chronic conditions like asthma and diabetes.

 

Wellmark's Affordable Care Act (ACA) Preventive Services List PDF File outlines what services are considered preventive for non-grandfathered, under 65 members.

Emergency services

In an emergency, such as a life-threatening illness or injury, you can go to any emergency room, whether it’s in or out of the network.

Hospitalization

Non-emergency hospital visits are covered when you are sick or injured and include procedures like lab work, X-rays and medication.

Prescription drugs

Approved medication prescribed by your doctor will be covered.

Maternity and newborn care

Comprehensive care throughout pregnancy and childbirth.

Mental health and substance-use disorder services, including behavioral health

Most plans covers counseling, psychotherapy and behavioral health treatments.

Rehabilitative and habilitative services and devices

If you need physical therapy, speech therapy or other therapy, your plan will pay for it along with any devices — like splints, braces or walkers — you may need.

Laboratory services

Lab services cover blood tests and screenings your doctor needs to diagnose illness and monitor long-term conditions like diabetes or high cholesterol.

Pediatric services, including dental and vision care

Babies and kids receive the same Essential Health Benefits, including well-child visits and immunizations.
Coverage/benefits vary by plan and market segment. Check your coverage documents for more information.
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Pre-existing conditions

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.

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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.

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Next: Coverage Exclusions