The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, provide a comprehensive package of items and services, known as Essential Health Benefits (EHBs). EHBs must include items and services within at least the following ten categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified and offer products in the Health Insurance Marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.
People with disabilities may need access to certain benefits and services that differ substantially either in amount, scope or duration from those required by members of the general public. For example, some individuals may need rehabilitation and habilitation services including occupational, physical, and/or speech therapy, behavioral health treatment, and devices such as complex wheelchairs. Others may require ongoing mental health treatment and non-generic prescription drugs, or ongoing diagnostic and specialty visits.
The role of Navigators is to provide fair and impartial information about all healthcare insurance options that are available. Within this role, they can help consumers understand how to determine if the scope and amount of essential health benefits are adequate to cover such services. Navigators also can provide information that will help people with disabilities understand how to evaluate and compare the cost of the benefits they require in relation to various insurance premium levels, co-payments, co-insurance, and deductibles. For example, in some cases, a more expensive monthly health insurance premium may reduce overall costs if out-of-pocket expenses for multiple visits, therapies, or for particular medications or types of equipment are lower in the more expensive plan.