What Are Essential Health Benefits?
The ACA established Essential Health Benefits (EHBs): ten categories of services that set a baseline for comprehensive coverage.
- Ambulatory patient services (outpatient care)
- Emergency services
- Hospitalization
- Maternity and newborn care
- 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
- Pediatric services, including oral and vision care
Which Plans Must Cover All Ten
- Individual and fully insured small group plans must cover all ten categories. All ACA metal-tier plans (Bronze, Silver, Gold and Platinum) include them. Grandfathered plans are an exception.
- Large group, self-funded and level-funded plans aren’t required to cover every category.
Pediatric dental: In the individual and small group markets, pediatric dental may sometimes be provided through a separate standalone dental plan rather than the medical plan. Rules vary by state.
Rules That Apply to EHBs in Most Plans
Even plans that don’t have to cover all ten categories follow these rules for any EHBs they do cover:
- No annual or lifetime dollar limits. See Prohibition on Annual & Lifetime Dollar Limits.
- Out-of-pocket maximum. Non-grandfathered plans, including large group and self-funded plans, must cap in-network cost sharing for covered EHBs at the ACA’s annual out-of-pocket maximum.
Important: This information is provided for general educational purposes. It is not legal or tax advice. How these rules apply depends on each employer’s specific circumstances, so employers should review their situation with their own legal counsel, ERISA attorney, CPA or tax advisor.