Health Insurance Benefits (2024)

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.

>>>Next: Health Insurance Costs

Health Insurance Benefits (2024)

FAQs

How do you explain insurance benefits to a patient? ›

The explanation of benefits lists the cost of your care, and how much your health insurance company will pay.
  1. “Provider Charges” is the amount your provider bills for your visit.
  2. “Allowed Charges” is the amount your provider will be paid. ...
  3. “Paid by Insurer” is the amount your health plan will pay to your provider.
Jun 22, 2023

What are the benefits of your health insurance? ›

Health insurance protects you from unexpected, high medical costs. You pay less for covered in-network health care, even before you meet your deductible. You get free preventive care, like vaccines, screenings, and some check-ups, even before you meet your deductible.

What is a consequence of not having health insurance in EverFi? ›

You must pay all costs for health care and medical emergencies. You're not allowed to go to a hospital. You will get a lower standard of care from doctors.

Is it worth it to pay for health insurance? ›

Health insurance can help reduce your risk of racking up medical debt. Only a handful of states enforce financial penalties if you don't have health insurance but it's still wise to have the financial protection.

How to get an explanation of benefits? ›

EOBs are usually mailed once per month. Some plans give you the option of accessing your EOB online. Your EOB is a summary of the services and items you have received and how much you may owe for them.

What best describes the benefits of having insurance? ›

Insurance is an important financial tool. It can help you live life with fewer worries knowing you'll receive financial assistance after a disaster or accident, helping you recover faster.

How does insurance benefit you? ›

Income replacement

Afford childcare, health care, or other services. Cover tuition or other college expenses. Eliminate household debt.

Why is health insurance the most important? ›

Health insurance provides important financial protection in case you have a serious accident or sickness. People without health coverage are exposed to these costs. This can sometimes lead people without coverage into deep debt or even into bankruptcy.

What are the 10 essential health benefits? ›

The Affordable Care Act requires non-grandfathered health insurance coverage in the individual and small group markets to cover essential health benefits (EHB), which include items and services in at least the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization ...

What is a disadvantage of having health insurance? ›

Disadvantages of private health insurance

Many individual policies can cost several hundred dollars a month, and family coverage can be even higher. And even the more comprehensive policies come with deductibles and copays that insureds must meet before their coverage kicks in.

Is health insurance necessary Why or why not? ›

Health insurance can help protect you from the high costs of illness or injury. It also helps you get regular health care, such as exams, preventive care and vaccines.

What are the negative effects of not having health insurance? ›

Lack of health insurance coverage may negatively affect health. Uninsured adults are less likely to receive preventive services for chronic conditions such as diabetes, cancer, and cardiovascular disease.

Do we really need insurance? ›

The answer—yes! Health insurance has a reputation for being expensive and confusing, but it can also be the only thing standing between you and financial disaster if you ever need medical care.

Which health insurance is the best? ›

  • Blue Cross Blue Shield. : Best all-around policies.
  • Oscar. : Excellent plan options.
  • Kaiser Permanente. : Lowest average deductible.
  • Cigna. : Excellent value.
  • Aetna. : Lowest premiums.
May 2, 2024

Why is health insurance so unaffordable? ›

Administrative Overhead: Health insurers often have substantial administrative overhead, including marketing, underwriting, and claims processing. These costs are passed on to consumers in the form of higher premiums, which can contribute to overall healthcare expenditure.

How do you explain insurance to someone? ›

Insurance is a way to manage your risk. When you buy insurance, you purchase protection against unexpected financial losses. The insurance company pays you or someone you choose if something bad happens to you. If you have no insurance and an accident happens, you may be responsible for all related costs.

What is an explanation of benefits from insurance? ›

What is an Explanation of Benefits? Each time your insurer pays for a service you use, they send you an Explanation of Benefits (EOB). The EOB is your insurance company's written explanation for that claim, showing the name of the provider that covered the service and date(s) of service.

What is the patient explanation of benefits? ›

An EOB is a statement from your health insurance plan describing what costs it will cover for medical care or products you've received. The EOB is generated when your provider submits a claim for the services you received. The insurance company sends you EOBs to help make clear: The cost of the care you received.

What is the best way to describe health insurance? ›

Health insurance provides important financial protection in case you have an accident or sickness. For example, health insurance may help to pay for doctors' services, medications, hospital care, and special equipment when someone is sick or injured, often in exchange for a monthly premium.

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