What Health Plans Cover in Tennessee

The short answer: every marketplace plan in Tennessee, and every ACA plan bought off the marketplace, must cover the same 10 essential health benefits, cover pre-existing conditions from day one, and give free in-network preventive care. Plans differ in what you pay and which doctors and drugs they include, not in the basic list of what's covered. The big gaps are adult dental, adult vision, long-term care, and often weight-loss drugs and fertility treatment.

The 10 essential health benefits

Every ACA-compliant individual and small-group plan covers:

1. Outpatient care: doctor visits, specialists, outpatient surgery
2. Emergency services: including at out-of-network hospitals
3. Hospitalization: surgery, overnight stays
4. Pregnancy, maternity, and newborn care: before and after birth
5. Mental health and substance use disorder services: including counseling and inpatient treatment
6. Prescription drugs: at least one drug in every category, per the plan's formulary
7. Rehabilitative and habilitative services: physical, occupational, and speech therapy
8. Laboratory services
9. Preventive and wellness care, and chronic disease management
10. Pediatric services: including dental and vision care for children

Plans can't put annual or lifetime dollar caps on these benefits. They can set visit limits (for example, a number of physical therapy visits per year) and require prior authorization.

Common questions by type of care

Preventive care. Recommended screenings, vaccines, and checkups are free in network, with no deductible or copay. That includes annual wellness visits, many cancer screenings, blood pressure and cholesterol checks, contraception, and well-child visits. If a visit turns into treating a problem, that part can cost money. The Supreme Court upheld the system behind these requirements in 2025.

Lung cancer screening. Adults 50 to 80 with a significant smoking history get a yearly low-dose CT scan as free preventive care. Insurance doesn't pay for home radon testing, the second leading cause of lung cancer, but Tennessee gives away free radon test kits. Radon and your family.

Lead testing for children. Blood lead screening for young children at risk is preventive care, so it's free in network. TennCare's checkups for children (TENNderCare) include blood lead tests, generally at 12 and 24 months. Health insurance doesn't pay to test your home's water or buy a filter. If you live in a home built before 1986 or on a private well, see Tennessee Water Authority's independent guides to lead in home plumbing and well water testing, and talk to your child's doctor about a blood test.

Doctor and specialist visits. Covered, with a copay or coinsurance. HMOs and POS plans usually require a referral for specialists. Network types.

Hospital and emergency care. Covered. You pay your deductible and coinsurance up to the out-of-pocket maximum. Emergency care at an out-of-network hospital is billed as in network under federal law.

Surgery. Medically necessary surgery is covered, subject to your deductible, coinsurance, and any prior authorization. Ask whether the surgeon, anesthesiologist, and facility are all in network.

Cancer and other serious illnesses. Covered as essential benefits, including chemotherapy, radiation, and hospital care. You still pay up to the out-of-pocket maximum, so a serious diagnosis usually means hitting it. Many insurers offer free case management; ask for it.

Chronic conditions like diabetes or heart disease. Covered, with no pre-existing-condition exclusions. Check that your specialists are in network and your medications are on the formulary.

Pregnancy and maternity. Covered on every ACA plan, including if you were already pregnant when coverage started. Pregnancy itself doesn't open a special enrollment period, but birth does. Pregnant women in Tennessee may qualify for TennCare or CoverKids up to 250% of the poverty level, and those enroll year-round. Families and pregnancy.

Mental health and substance use. Covered, and federal parity rules mean plans can't make these benefits more restrictive than medical benefits, for example with tighter visit limits or higher copays.

Physical therapy and rehab. Covered, often with visit limits or prior authorization.

Telehealth. Most Tennessee marketplace plans cover virtual visits, often at a low or zero copay. Check the plan's SBC.

Prescription drugs. Covered if the drug is on the plan's formulary. Check each drug by name and dose. Formularies and drug tiers.

What's often not covered, or limited

Adult dental. Not an essential benefit for adults. HealthCare.gov sells separate dental plans you can add, or you can buy one directly from a dental insurer. Children's dental is an essential benefit; on the marketplace it may be built into the health plan or sold as a separate dental plan. For what dental work costs and how dental insurance works, see Tennessee Dental Authority, an independent dental-care guide: how dental insurance works and what dental work costs in Tennessee.

Adult vision. Routine eye exams and glasses for adults generally aren't covered. Medical eye care, like treatment for glaucoma, is. Children's vision care is an essential benefit.

GLP-1 drugs for weight loss (Wegovy, Zepbound). Coverage varies by plan. Many plans cover GLP-1s like Ozempic and Mounjaro for type 2 diabetes but exclude or restrict them for weight loss alone, often with prior authorization. Check the formulary for the exact drug and any notes about restrictions.

Fertility treatment and IVF. Not an essential benefit, and Tennessee doesn't require individual health plans to cover it. Diagnosis of infertility may be covered; treatment such as IVF usually isn't. Read the plan's exclusions.

Long-term care. Nursing home or in-home custodial care isn't covered by health insurance. TennCare's long-term services program (CHOICES) and private long-term care insurance are separate.

Cosmetic procedures, most alternative therapies, and care outside the U.S. are commonly excluded.

Every plan's SBC has a section called "Services Your Plan Generally Does NOT Cover." Read it before you enroll.

Waiting periods

ACA marketplace plans don't have waiting periods for pre-existing conditions: coverage starts on your effective date. Employer plans can make new hires wait up to 90 days to become eligible. Non-ACA plans are different: Farm Bureau health plans commonly impose 6 to 12 month waiting periods for pre-existing conditions, and short-term plans can exclude them entirely.

Major medical vs. hospital indemnity and other add-ons

Major medical coverage (any ACA plan) pays a share of a broad range of care and caps your yearly costs.

Hospital indemnity, critical illness, and accident plans pay you a fixed cash amount, for example $200 per day in the hospital or a lump sum after a diagnosis. They don't pay your medical bills directly, have no out-of-pocket cap, and don't replace major medical coverage. They can supplement a high-deductible plan, but read what triggers a payment.

Frequently asked questions

What does a marketplace plan actually cover? The 10 essential health benefits: doctor visits, emergency care, hospital stays, maternity and newborn care, mental health and substance use treatment, prescriptions, rehab, lab work, preventive care, and children's dental and vision. The SBC shows each plan's costs and limits.

Does health insurance cover dental and vision? For adults, generally no. You can add a separate dental plan on HealthCare.gov. Children's dental and vision are essential benefits. For dental costs and coverage in Tennessee, see Tennessee Dental Authority, an independent guide.

Does it cover pre-existing conditions? Yes. ACA plans can't deny you, charge you more, or exclude a condition because of your health history. Non-ACA options like short-term and Farm Bureau plans can. Pre-existing conditions guide.

Does it cover pregnancy if I'm already pregnant? Yes, if you're enrolled in an ACA plan. If you're uninsured and pregnant outside open enrollment, check TennCare and CoverKids, which take applications year-round.

Is preventive care really free? Yes, for recommended preventive services from in-network providers. You may be charged if the visit also treats a problem or if you go out of network.

Are GLP-1 drugs like Ozempic or Wegovy covered? It depends on the plan and the reason. Coverage for diabetes is common; coverage for weight loss alone is often excluded or restricted. Check the formulary and prior authorization requirements for the exact drug.

Is IVF covered? Usually not. It isn't an essential health benefit, and Tennessee has no law requiring individual plans to cover it.

Do marketplace plans have waiting periods? No. Coverage, including for pre-existing conditions, starts on your effective date.

What's the difference between major medical and a hospital indemnity plan? Major medical pays a share of your actual medical bills with a yearly cap on your costs. An indemnity plan pays a fixed cash amount per day or event and doesn't replace real coverage.

Are there dollar limits on what the plan will pay? Not on essential health benefits. ACA plans can't set annual or lifetime dollar caps or room-rate limits on them, though they can limit visits for some services.

Does health insurance pay for water testing or a water filter? No. Health plans pay for medical care, not home water testing or treatment. They do cover recommended preventive care like blood lead screening for at-risk children. For what's in your water and how to test it, see Tennessee Water Authority's drinking water contaminants guide, an independent Tennessee resource.

Keep reading

• How to read a plan's cost table
• Formularies and drug tiers
• Prior authorization and referrals
• Have a health condition? What protects you

Sources

• CMS EPSDT policy and TennCare TENNderCare — blood lead screening for children; Bright Futures/HRSA preventive guidelines
• HealthCare.gov — essential health benefits, preventive care benefits, dental coverage in the marketplace
• 42 U.S.C. 18022 and 45 CFR 156 — essential health benefits; ban on annual and lifetime limits
• Mental Health Parity and Addiction Equity Act — parity for mental health and substance use benefits
• Kennedy v. Braidwood Management (U.S. Supreme Court, June 27, 2025) — preventive services requirement upheld
• KFF state benefit mandate tracking and WBIR reporting — Tennessee has no infertility coverage mandate for individual plans
• Tennessee Farm Bureau health plan materials (as summarized on our Farm Bureau page) — waiting periods
• U.S. Department of Labor — 90-day maximum waiting period for employer plans