Essential Health Benefits

The Affordable Care Act (ACA) requires fully insured small group and individual health plans (both on and off the public exchange/Marketplace) provide coverage for a core package of health care services, known as "essential health benefits" (EHBs). This rule is intended to balance comprehensiveness and affordability for consumers by ensuring essential services are covered and consumer out-of-pocket expenses are limited.

EHB categories

In addition to the standard 10 EHB categories detailed below, states may include additional benefit requirements under their own state regulations or within a state's selected benchmark plan.

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance abuse disorder services (including behavioral health treatment)
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Any health plan that covers EHBs must cover these benefits with no annual limits or lifetime maximums. This includes self-insured and large group plans (having 51 or more employees). Effective January 1, 2017, plans that offer out-of-network benefits on EHBs may no longer place limits or maximums on those benefits.

Out-of-pocket limits on EHBs

Out-of-pocket (OOP) consumer spending, which typically includes deductibles, copays and coinsurance, is limited for in-network essential health benefit services. The OOP spending limits are adjusted annually and can be found on our Cost Sharing page.

State benchmark plans

The Department of Health and Human Services (HHS) regulates EHBs based on State-specific EHB-benchmark plans. The Final 2019 HHS Notice of Benefits and Payment Parameters established standards for states, giving them greater flexibility in choosing to update their EHB-benchmark plans.

It's important for employers who sponsor group health plans to understand which benchmark plan they must follow so they know which benefits cannot have annual or lifetime limits. The state benchmark plan is determined differently based on the plan's funding type:

• Employers that self-insure their plans can choose a state to use for their benchmark plan.
• Employers with insured plans must use the benchmark plan of employer's contract/situs state, except for HMO plans which must follow the HMO plan state.

For more information on state benchmark plans, visit Information on Essential Health Benefits (EHB) Benchmark Plans.