Is your organization ACA compliant? ACA Compliancy Checklist

First of all let’s start with the most important question. Does your company or organization offer health care coverage for its employee’s that meet ACA compliancy? That surely leads you to ask, “How do I know if I’m ACA compliant” or “What makes your health plan ACA compliant?” There are roughly 10 major components of compliancy under the ACA. This means that at a minimum any new health plans adopted by your organization from 2014 onward must include these 10 benefits at a minimum. All plans sold in individual and small group markets, including plans sold on and off the Health Insurance Marketplace, and Government healthcare plans like Medicaid and Medicare all include at least these 10 Essential Benefits. I will list these out in a bulletin board fashion and then elaborate on each of these and what they mean later.




  1. Ambulatory Care is care that you might obtain while visiting a doctor for an annual checkup or if you’ve come down with a cold or flu and need to see a doctor in their office. It’s basically outpatient care you obtain without being admitted to a hospital.
  2. Emergency Services is care that you receive for conditions that could lead to serious disabilities or death if not treated. An example would be a car accident where you are seriously injured while traveling on a vacation. Typically this coverage includes transportation to the hospital via ambulance. You are also not penalized if you have to go out of your health plan’s coverage area, nor are you penalized for not having prior authorization or pre-acceptance.
  3. Hospitalization is any care, services, prescriptions, doctor visits, nursing, special care, tests, lab work, and room and board that you incur as a result of being hospitalized. It’s always a good idea to understand your individual policy on Hospitalization because there can be varying degrees of coverage including things like limited stays for certain conditions or where elderly care is involved.
  4. Maternity and Newborn care is coverage before, during and after your baby is born. This includes covering your newborn baby immediately after delivery.
  5. Mental Health Services and Addiction Treatment are services that cover psychotherapy, counseling, behavioral healthcare treatment plans and substance abuse disorders.
  6. Prescription Drugs is probably the trickiest because it does have some limitations that can be different based upon what your provider offers. A basic plan is going to cover most medications that are approved by the FDA, but there are some exclusions allowed. Over the counter drugs are generally not covered even if your doctor writes you a prescription for such. Some insurance companies will only cover generic drugs for example unless it can be proven that the generic drug doesn’t work.
  7. Rehabilitation services and devices are also covered, but like prescription drugs have some limitations depending upon the provider. Examples of this type of coverage would be if you needed speech therapy, chiropractic services, or any kind of physical therapy to help you rehabilitate. Plans also have to provide 30 visits each year for either physical or occupational therapy, or visits to the chiropractor. Plans must also cover 30 visits for speech therapy as well as 30 visits for cardiac or pulmonary rehab.
  8. Laboratory Services is any testing issued by a doctor to help them diagnose an injury, illness or condition, or to monitor the effectiveness of a particular treatment. Some preventive screenings, such as breast cancer screenings and prostrate exams, are provided free of charge under some plan providers.
  9. Preventative Services are annual checkups or ongoing checkups to treat diabetes or asthma. They can be classified as cancer screenings. Basically any testing or checkups that are designed to prevent or detect certain medical conditions.
  10. Pediatric Services is care provided to infants and children and typically include well-child checkups, immunizations and vaccinations. Of particular note is that vision and dental care must be included for children up through age 19. Specifically it includes two dental exams, an eye exam and corrective lenses each year.

It’s important to note that each medical plan your organization offers from January 1, 2014 onward must cover these essentials. All employees should be made aware that the scope and breadth of these benefits can differ drastically from provider to provider. For specific details of the act and the benefits required by employers and state exchanges (referred to as insurance exchange/marketplace providers) readers can find the 974 page document entitled Patient Protection and Affordable Care Act (Public Law 111–148) and turn to the Section 1302 (b) (2) (a).

Tags: ,