Ask a question

Questions & answers · Health insurance

Does my health plan have to cover this? What do Marketplace plans cover?

Health insuranceWho paysChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: HealthCare.gov View original ↗

In short

  1. All Marketplace plans must cover 10 kinds of care.
  2. Adult dental and vision are not part of that list.
  3. If a service was denied, you have 180 days to appeal.

What this means

HealthCare.gov lists 10 kinds of care all Marketplace plans must cover [1]: 1. Care you get without a hospital stay 2. Emergency care 3. Hospital stays, like surgery 4. Care for pregnancy, birth and newborns 5. Mental health and drug or alcohol care, like counseling 6. Prescription drugs 7. Rehab care and devices 8. Lab tests 9. Care to stay well, and care for long-term illness 10. Care for children, including dental and eye care

Adult dental and vision are not on the list [1].

This list is for Marketplace plans. Large employers that "self-insure" pay their workers' care costs directly. HealthCare.gov says they don't have to give these benefits, but many do. Ask your employer [1].

If your plan denies a service, you can appeal. File within 180 days of the denial notice [2].

Your next step

Look for the service in your plan papers. If it was denied, file your internal appeal within 180 days (6 months) of the denial notice [2].

Check it yourself

Open HealthCare.gov's "What Marketplace health insurance plans cover" and read the list of 10. Whether your exact service is paid, and what you pay, is in your own plan papers — the sources here can't say.

Where this comes from (2)

  1. [1] HealthCare.gov · checked 2026-11-06

    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 (this includes counseling and psychotherapy) … Prescription drugs … Rehabilitative and habili…
  2. [2] HealthCare.gov · Internal appeals (row aca-hc-int) · checked 2026-11-06

    You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.

How we found this

We matched your question to 2 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

Related answers

Answer id CQ42. Spotted an error? Tell us.