Affordable Care Act mandates 10 essential health benefits

‘Continuum of care’

Editor’s note: This is the first in a series of stories that will explain the 10 essential health benefits required under the Affordable Care Act and explore what effect those requirements will have on patients and caregivers.


The Affordable Care Act (ACA) requires all health insurance plans in the Marketplace to cover 10 essential health benefits. And in some cases, those 10 essential benefits fall in line with how health care providers are already evolving their care.

The 10 essential health benefits are: outpatient care; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorders and behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services.

Have questions?

We want to answer your questions regarding the Affordable Care Act; email reporter Olivia Ingle at olivia@newstribun... or call her at 573-761-0248.

Also, feel free to share your experiences with the ACA or your experiences signing up for coverage in the Marketplace.

The ACA is a law signed by President Barack Obama in 2010. According to the U.S. Department of Health and Human Services, the law seeks to strengthen the health care system by extending health coverage to the uninsured, improving health care quality and patient safety, emphasizing primary and preventive care, reducing health care costs, ensuring access to quality health care and promoting use of health information technology. The law also requires everyone to have health insurance in 2014, or otherwise pay a fine.

The health insurance marketplace is part of the law. The marketplace,, opened for enrollment Oct. 1 and allows individuals to shop for health insurance plans. Some may even qualify for subsidies to help pay for the plans.

Every plan must cover the 10 essential health benefits, unless it’s a plan exempted for 2014 because of Obama’s statement earlier in the year that “if you like your plan you can keep it.” Exempt individuals are those who received unexpected health insurance cancellation notices in October.

Janet Weckenborg, vice president of operations at Capital Region Medical Center (CRMC) in Jefferson City, said the 10 essential health benefits involve care at the time of crisis, but they also involve health care as an individual goes through life.

“When you look at the 10 things and what they’re trying to do, they’re trying to cover the continuum of care,” she said.

Outpatient care

Outpatient care — one of the ACA’s 10 essential health benefits — is care you get without being admitted to a hospital.

Tony Houston, executive vice president and chief operating officer at St. Mary’s Health Center (SMHC) in Jefferson City, said outpatient care has evolved over time.

“Things where you had to come to the hospital before and stay, can be done now on a day surgery perspective,” he said. “That’s just the progression of the science, the progression of the equipment and the progression of the skill of the caregivers. And, that’s going to continue.”

For example, Houston said, gall bladder surgery and gastrointestinal procedures are two services that have for the most part become outpatient services.

“The majority of gall bladder surgeries today, patients come and go home the same day,” Houston said. “That’s an example of a huge change. It’s much more rare to come into the hospital and have to spend the night for an extended period of time to remove your gall bladder today than it was even 15 years ago.”

He said outpatient services include more than services for some sort of ailment or the need for a specific exam.

“I do think the push on outpatient is something that goes well beyond that sick episode,” he said. “It’s wellness and building that relationship with your primary caregiver so that hopefully we avoid those acute ailments that over time build up and cause you to have to go spend time in the hospital.”

Weckenborg agreed.

“It (outpatient care) is things you can do so that you stay healthier and you don’t just access care in critical situations,” she said.

Outpatient care in Jefferson City

CRMC and SMHC are adapting to a more outpatient-focused health care industry. Both hospitals have centered facility expansion around the issue.

“We think that it’s just natural for us to take the opportunity to expand our current medical center’s footprint with additional outpatient options and services,” Weckenborg said. “We see this as an opportunity with that shift in the provision of care from the inpatient hospital delivery to the outpatient focus.”

CRMC announced in May a $35 million expansion of its current campus at 1125 Madison St. The expansion increases hospital space by a third, adding two floors of medical offices and additional rooms for outpatient services.

St. Mary’s Health Center is currently building a new facility at Missouri 179 and Mission Drive. The new St. Mary’s Health Center is set to open at the end of 2014.

“If you look at even our new campus, a lot of our new campus is positioned for the outpatient,” Houston said. “We’re trying to be more convenient, more accessible to people who are coming in and leaving in that same day. We’re trying to recognize that and serve the community in a way that is much more beneficial for them.”

Weckenborg said she sees the benefit of outpatient care for patients.

“When they look at the opportunity to return home at night, I think most people would do that,” she said.

10 essential health benefits

Under the Affordable Care Act, all insurance plans in the Marketplace are required to cover:

• Ambulatory patient services (outpatient care you get without being admitted to a hospital)

• Emergency services

• Hospitalization (such as surgery)

• Maternity and newborn care (care before and after your baby is born)

• Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)

• Prescription drugs

• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions to gain or recover mental and physical skills)

• Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric services

Have questions?

We want to answer your questions regarding the Affordable Care Act; email reporter Olivia Ingle at or call her at 573-761-0248.

Also, feel free to share your experiences with the ACA or your experiences signing up for coverage in the Marketplace.


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