The ACA established Essential Health Benefits (EHBs) – ten categories of services that define a comprehensive baseline of coverage.
Individual and fully insured small group plans must cover all ten categories.
Large group, self-funded, and level-funded plans are not required to cover every category, but any EHBs they do cover cannot have annual or lifetime dollar limits.
The 10 EHB categories are:
- 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
Key Rules
- Individual and small group plans: Must cover all 10 categories. All ACA metal tier plans include coverage for all ten EHB categories.
- Large group, self-funded, and level-funded plans: Not required to cover every category, but any EHBs they do cover cannot have annual or lifetime dollar limits. Many voluntarily include most or all EHBs.
- Pediatric dental and vision: Required in the individual and small group market, but these can sometimes be offered through standalone dental/vision plans if not embedded in the medical plan