What Does Every Marketplace Health Insurance Plan in North Carolina Have to Cover?

Every Marketplace health insurance plan in North Carolina covers ten essential health benefits, plus birth control and breastfeeding. Billy Jordan of The Jordan Insurance Agency explains what’s always included and what extras you might see.

In this episode

• Learn the ten essential health benefits every plan must include in North Carolina
• Find out which dental and vision benefits are required for adults and children
• Discover what extras and preventive services may be included in your plan

Source: Health benefits & coverage (healthcare.gov)

Billy Jordan is a licensed insurance agent (NPN 8699876) with The Jordan Insurance Agency, based in Charlotte, North Carolina. Voices in this episode are AI-generated, including Billy's, from a script reviewed and approved by Billy Jordan, a licensed insurance agent. General education only, not advice for your specific situation.

Tanya (AI host): What does every Marketplace health insurance plan in North Carolina have to cover? If you’re shopping for coverage, you’ll want to know what’s included—and what’s not.

Tanya (AI host): Welcome to Smart Coverage. Real Advice., the insurance podcast from The Jordan Insurance Agency. I'm Tanya, your host, and I'm here with Billy Jordan, a licensed insurance agent and the president of The Jordan Insurance Agency.

Billy Jordan: Glad to be here, Tanya. That’s a great question. Let’s talk about what you can count on with Marketplace health plans in North Carolina.

Tanya (AI host): So, Billy, if I buy a health plan through the Marketplace, what does it have to cover, no matter which plan I pick?

Billy Jordan: Every Marketplace plan in North Carolina has to cover what are called “essential health benefits.” There are ten of them—and every plan, no matter the metal level or whether it’s an HMO or PPO, has to include these. According to healthcare.gov, the list covers ambulatory patient services (outpatient care you get without being admitted to a hospital), emergency services, hospitalization (like surgery and overnight stays), pregnancy, maternity, and newborn care (both before and after birth), 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 for children. So, wherever you shop on the Marketplace, these basics are always included.

Tanya (AI host): That’s a lot! So, if I sign up, I know those ten things are part of my coverage. Can you give me a real-world example of how that plays out?

Billy Jordan: Sure. For example, if you need outpatient physical therapy after a knee injury, “rehabilitative and habilitative services and devices” are one of the essential health benefits, so your plan will include coverage for that therapy. The details can differ by plan, but the coverage itself is always there.

Tanya (AI host): What’s a mistake people make with this?

Billy Jordan: A common mistake is thinking all plans cover the same things in the same way. The essential health benefits are the minimum required, but each plan can cover additional services or handle those ten benefits differently. It’s important to check the details for each plan.

Tanya (AI host): Okay, so those are the big ten. Are there any other benefits that plans have to cover, or is that it?

Billy Jordan: In addition to those ten, Marketplace plans must also include birth control coverage and breastfeeding coverage. These are required benefits, too.

Tanya (AI host): And what about things like dental and vision?

Billy Jordan: For adults, dental and vision aren’t considered essential health benefits—so not every Marketplace plan includes them. But for children, pediatric services always include oral and vision care.

Tanya (AI host): That’s helpful! But what if an adult really wants dental or vision coverage with their health plan?

Billy Jordan: Some plans may offer dental or vision as additional benefits for adults, but it’s not required. When you compare plans, you’ll see which ones include those extras.

Tanya (AI host): Are there any other extras or programs people might see in a Marketplace plan?

Billy Jordan: Yes, some plans offer additional benefits like medical management programs for specific needs such as weight management, back pain, or diabetes. These are not required, so you’ll see those details when you compare your options.

Tanya (AI host): What about preventive care? Is that always covered, or does it depend on the plan?

Billy Jordan: Preventive and wellness services and chronic disease management are always covered as essential health benefits. Some preventive services are free, meaning you don’t have to pay a deductible or copay for them.

Tanya (AI host): So, if I go in for my yearly check-up, that’s covered with no charge?

Billy Jordan: That’s right, as long as it’s a covered preventive service.

Tanya (AI host): Are all these benefits the same in every state, or do they change in North Carolina?

Billy Jordan: According to healthcare.gov, essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on North Carolina’s requirements.

Tanya (AI host): What if someone needs a treatment that’s not on the essential benefits list?

Billy Jordan: Plans may cover other services. When you compare plans, you’ll see more detailed information about what’s covered. If you want to find out if a particular service is covered, check the plan details or contact the plan.

Tanya (AI host): And if someone’s on a plan through work, do these same benefits always apply?

Billy Jordan: Not always. Large employers who self-insure—meaning they pay employees’ health care costs directly—don’t have to provide essential health benefits. Many do, but you have to check with your employer to see what’s covered.

Tanya (AI host): Three things to remember. One, every Marketplace plan in North Carolina covers the ten essential health benefits, plus birth control and breastfeeding coverage. Two, pediatric services always include oral and vision care, but adults may need to look for plans that offer those as extras. Three, some preventive services are free, and you should check your plan for details and any additional benefits.

Tanya (AI host): For a personalized look at your situation, book a free thirty-minute chat with Billy and his team at thejordaninsuranceagency.com/podcast.

Billy Jordan: I'm Billy Jordan with The Jordan Insurance Agency. Until next time, take care.

Tanya (AI host): Thanks for listening to Smart Coverage. Real Advice. from The Jordan Insurance Agency.