Essential benefits in California

One of the main goals of the Affordable Care Act was to make health insurance not only affordable, but comprehensive.

The federal law contains a set of “essential health benefits” that providers must guarantee buyers of individual or small-business insurance policies.

health care instrumentThe White House has said repeatedly that the Obamacare guarantees eliminate “substandard policies that don’t provide minimum services.” Being underinsured can be every bit as dangerous to your finances as not being insured at all, consumer advocates say.

Maternity, addiction and mental health problems were among the areas typically left uncovered by individual policies.

States were allowed to craft their own set of essential health benefits, using one of several “benchmarks” set by previously existing insurance plans. In California, that plan was the Kaiser Small Group HMO 30 plan.

Federal essential health benefits (alphabetical order):

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health services
  • Substance abuse disorder services
  • Prescription drugs
  • Rehabilitative and “habilitative” services and devices
  • Laboratory services
  • Preventive and wellness services
  • Chronic disease management
  • Pediatric services, including oral and vision care

California’s additions to the essential health benefits emerged from the state Legislature in 2012. The key pieces of legislation were Assembly Bill 1453 (Monning) and Senate Bill 951 (Hernandez). Both were signed into law in late September 2012.

State of California essential health benefits:

  • Preventive services for children 16 and younger
  • Mental health parity
  • Autism care including behavioral health treatment
  • Prescription drug coverage for contraceptives
  • Maternity hospital stay
  • Maternity: Inpatient hospital and ambulatory
  • AIDS vaccine
  • HIV testing
  • Organ transplants for HIV
  • Diabetes education, management and treatment
  • Alpha feto protein testing
  • Prosthetics for laryngectomy
  • Reconstructive surgery
  • Mastectomies and lymph node dissections
  • Mammography
  • Cervical cancer treatment
  • Cancer screening tests
  • Cancer clinical trials
  • Prostate cancer treatment
  • Osteoporosis treatment
  • Surgical procedures for jaw bones
  • Anesthesia for dental
  • Conditions attributable to diethylstilbestrol
  • Hospice (end of life) care
  • Pain management medication for terminally ill
  • Emergency response ambulance or ambulance transport services
  • Phenylketonuria treatment
  • Sterilization operations and procedures

View the California health care legislation page
View the California Health and Safety Code, section 1367.005