Essential Health Benefits

The Affordable Care Act (ACA) requires all health insurance plans in the individual and small group markets to offer a certain set of Essential Health Benefits. This would apply to all new plans as of Jan. 1, 2014 both on and off the exchange.

10 Essential Health Benefits

  • Ambulatory patient services (Outpatient care that you receive without being admitted to the hospital)
  • Emergency services
  • Hospitalization (Inpatient care such as surgery and overnight stays in the hospital)
  • Maternity and newborn care (Including before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (Services that help you gain or recover mental and physical skills after an injury, a disability or a chronic condition)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including some dental and vision care (included for children only)

Important to know:

  • The ACA banned annual or lifetime coverage caps on essential health benefits
  • Preventive care, vaccinations and medical screenings cannot be subject to any cost-sharing when received in network
  • Grandfathered plans,  large group health plans, and certain ERISA type plans are exempt from the Essential Health Benefit requirement
  • States have the discretion to determine specific benefits they deem essential, so benefits can vary from state to state and even include additional services as a requirements