What's covered

Essential care covers what you'd expect — and some things you might not have today. Mental health, dental, vision, hearing, and prescription drugs are built in from day one — not add-ons, not extras.

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Primary & Preventive

  • Primary care visits
  • Annual wellness exams
  • Preventive screenings (always $0)
  • Vaccinations and immunizations (always $0)
  • Lab work and diagnostics
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Specialist & Hospital

  • Specialist consultations
  • Emergency room and urgent care
  • Inpatient and outpatient hospital care
  • Surgery and anesthesia
  • Physical and occupational therapy
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Mental Health

  • Therapy and psychiatry — same access as any other care
  • Substance use treatment and detox
  • Inpatient behavioral health
  • Crisis intervention services
  • Telehealth mental health visits
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Prescription Drugs

  • Generic and brand-name prescriptions
  • No coverage gaps or donut holes
  • National cost-plus pricing (cost + 15%)
  • Drug costs count toward your 5% AGI annual cap
  • Specialty drugs including biologics
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Dental & Vision

  • Preventive cleanings and exams
  • Fillings and medically necessary dental work
  • Dentures and orthodontics (medically necessary)
  • Eye exams and prescription glasses
  • Hearing exams and hearing aids
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Maternity & Reproductive

  • Prenatal and postnatal care
  • Labor and delivery
  • Reproductive health services
  • Fertility counseling
  • Newborn care
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Long-Term & Home Care

  • Home health aide services
  • Skilled nursing facility care
  • Hospice and palliative care
  • Durable medical equipment
  • Chronic disease management
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Telehealth

  • Video and phone visits reimbursed at 80% of in-person rate
  • Same co-pay as equivalent in-person visit
  • Available for most primary and specialty care
  • No additional setup fees

What's not in the essential benefit

The HTF covers essential care. A few categories remain optional or supplemental:

  • – Luxury hospital accommodations (private suite upgrades)
  • – Elective cosmetic procedures
  • – Non-medically-necessary dental upgrades (e.g., veneers)
  • – Experimental treatments not yet MAC-approved

Private supplemental insurance can cover these extras. HSAs remain available for co-pays and non-essential services.

What stays unchanged

  • VA and TRICARE: Continue as-is. Eligible beneficiaries may choose to use AMERICA Act instead — nobody is forced to switch.
  • Indian Health Service: IHS continues. Tribal members may elect AMERICA Act coverage for expanded access.
  • HSAs: Health Savings Accounts are preserved for co-pays, non-essential services, and supplemental coverage.
  • Private supplemental plans: Insurers can offer plans covering extras, upgrades, and elective services.

Your rights under this law

No prior authorization
Your doctor decides what you need — not an insurance company.
No balance billing
What the program pays plus your co-pay is the full bill. Providers cannot charge more.
Free choice of provider
Any licensed provider nationwide. No networks, no gatekeepers.
No denials of covered care
Violations carry penalties up to $100,000 per incident.
Coverage continuity
Active treatment (cancer, pregnancy, dialysis) continues uninterrupted for at least 12 months during transition.
Hardship waivers
If co-pays would cause financial hardship, IRS-verified waivers are available.