Essential Health Benefits

Under the Affordable Care Act (ACA), both fully insured small group and individual health plans, whether obtained on or off the Exchange/Marketplace, are required to include essential health benefits (EHB).

Essential health benefits are the minimum standards for all Marketplace plans, although plans may offer additional coverage options. When comparing plans side-by-side on the Marketplace, you can see the specific details of what each plan includes.

The essential health benefits mandated by the Patient Protection and Affordable Care Act encompass the following broad categories:

  • Ambulatory patient services (outpatient care received without hospital admission)

  • Emergency services

  • Hospitalization

  • Maternity and newborn care (care provided before and after childbirth)

  • Mental health and substance use disorder services, including behavioral health treatment (such as counseling and psychotherapy)

  • Prescription drugs

  • Rehabilitative and habilitative services and devices (services and devices to assist individuals with injuries, disabilities, or chronic conditions in gaining or recovering physical and mental skills)

  • Laboratory services

  • Preventive and wellness services, including chronic disease management

  • Pediatric services, including oral and vision care

According to the ACA, all plans, regardless of size and including self-funded plans, that cover essential health benefits must do so without imposing annual limits or lifetime maximums.