Benefits and Exclusions
Health care benefits vary by plan. This means that some plans might cover a particular treatment or service, while another plan might not. All Texas plans, however, must cover 10 essential health benefits:
- ambulatory patient services (outpatient care you get without being admitted to a hospital)
- emergency services
- hospitalization (including surgery)
- maternity and newborn care
- mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy)
- prescription drugs
- rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care
How to Compare Benefits and Exclusions
To compare the benefits offered by different plans, read each plan's summary of benefits and coverage (starting on page 2). This outlines the plan's benefits, cost-sharing , and exclusions. If you want more detail, such as the full list of plan exclusions, request a plan's terms and conditions, sometimes called disclosures.
You should also make sure a plan covers any prescription drugs that you need. Review the plan's drug formulary to find out if the plan covers a particular drug. Be sure to understand the cost sharing tiers associated with different types of drugs. For example, a generic drug may be in a low cost tier while a specialty drug may be in a high cost tier.
Remember to weigh the benefits different plans offer. Think about the kind of benefits you need now and might need in the future. Then consider plans that meet those needs.
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Last updated: 10/12/2015