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The Affordable Care Act's Essential Health Benefits

Explaining the Essential Health Benefits provided by the Affordable Care Act

Explaining the Essential Health Benefits provided by the Affordable Care Act

Essential Health Benefits

The Affordable Care Act (ACA) mandates that Individual/Family Health Plans and Small Employer Group Health Plans must cover Essential Health Benefits.

What are “essential health benefits”?

The Affordable Care Act requires insurance carriers to provide coverage for a package of Essential Health Benefits (EHB) in 10 benefit categories, effective the first plan year on or after January 1, 2014.

The requirement applies to all fully insured health plans offered in the Small Group and Individual health plans and includes all product types, whether HMO, PPO, POS or high-deductible HRA/HSA. In addition, the requirement affects plans both in and outside the Health Insurance Marketplaces (Exchanges) being established in states for 2014.

The mandate to cover EHB does not apply to fully insured Large Group, self-funded or grandfathered health plans.

The 10 designated benefit categories of essential health benefits are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Mental health and substance abuse services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and rehabilitative services and devices
  • Preventive and wellness services, and chronic disease management
  • Pediatric services, including oral and vision care

Of the designated EHB categories, the only ones that have not been traditionally covered in insured plans are Pediatric Dental and Vision services.