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Essential Health Benefits

The Affordable Care Act helps ensure that Americans have access to quality, affordable health insurance that includes a robust range of health care services. To achieve this goal, the law ensures that health plans offered in the individual and small group markets, both inside and outside of Health Insurance Marketplaces, offer a core package of items and services, known as “essential health benefits.” Under the statute, Essential Health Benefits (EHB) must include items and services within at least the following ten categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use 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

The Affordable Care Act also directs that EHB be equal in scope to benefits offered by a “typical employer plan.” EHB in each state is based on a state-specific benchmark plan. States were able to select a benchmark plan from among several options. The benchmark plan options included: 1) the largest plan by enrollment in any of the three largest products by enrollment in the state’s small group market; 2) any of the largest three state employee benefit plan options by enrollment; 3) any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by enrollment; or 4) the HMO plan with the largest insured commercial non-Medicaid enrollment in the state.

If a benchmark plan did not include items or services within one of more of the 10 statutory categories of benefits, the regulations provides direction on how the benchmark plan was to be supplemented.

Preventative Care

Under the Affordable Care Act, certain preventive services that have strong scientific evidence of their health benefits must be covered (by non-grandfathered private plans) and plans can no longer charge enrollees a copayment, coinsurance or deductible for these services (though a network plan may impose cost-sharing for receiving them out-of-network if they are available in-network). These services include those that are given an “A” or “B” rating by the United States Preventive Services Task Force (USPSTF), such as mammograms and cervical cancer screenings.

Additional coverage guidelines take into account the unique health needs of women throughout their lifespans and include breastfeeding support and supplies, contraception, prenatal care and other services. They must be covered by health plans without cost sharing. The health plan coverage guidelines, developed by the Institute of Medicine (IOM) and adopted by the Department of Health and Human Services will help ensure that women receive a comprehensive set of preventive services without having to pay a co-payment, co-insurance or a deductible. The Women’s Preventive Services guidelines are found here.

Frequently Asked Questions about Women’s Preventive Services are found here.

More information on coverage of women’s preventive services can be found here.

The regulations also include standards to protect consumers against discrimination and ensure that benchmark plans offer a full array of EHB benefits and services. Additional provisions include:

All Marketplace plans subject to EHB are required to offer benefits substantially equal to the benefits offered by the benchmark plan, supplemented if necessary. This approach strikes the balance between comprehensiveness, affordability, and state flexibility. See Essential Health Benefits, Actuarial Value & Accreditation Standards for more information.

Contraceptive Coverage

Because of the Affordable Care Act, most health plans cover recommended women’s preventive services, including contraception prescribed by a health care provider, without charging cost sharing, such as a co-pay, co-insurance, or deductible. The independent Institute of Medicine (IOM) provided recommendations to the Department of Health and Human regarding which preventive services help keep women healthy and should be considered in the development of comprehensive guidelines for preventive services for women.

All Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures and patient education and counseling for women with reproductive capacity, as prescribed by a provider, must be provided without cost-sharing. There are proven health benefits for women that come from using contraception. In fact, nearly 99 percent of women in the United States have relied on contraception at some point in their lives, but more than half of women between the ages of 18 and 34 have struggled to afford it2.

The IOM guidelines which were incorporated into the Health Resources Services Administration’s (HRSA) Women’s Preventive Services Guidelines include contraceptive methods and counseling to include “all Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.

The Affordable Care Act3 also ensures that recommended preventive care, including all FDA-approved contraceptive services prescribed by a health care provider, will be provided to women without cost-sharing, while also ensuring certain non-profit religious organizations that object to contraceptive coverage on religious grounds do not have to contract, arrange, pay, or refer for such coverage for their employees or students.

Frequently Asked Questions regarding contraceptive services can be found here.

Fact Sheet: Women’s Preventive Services Coverage, Non-Profit Religious Organizations, and Closely-Held For-Profit Entities is here.

2 "Fact Sheet: Women’s Preventive Services and Religious Institutions,” The White House, February 10, 2012 www.whitehouse.gov/the-press-office/2012/02/10/fact-sheet-women-s-preventive-services-and-religious-institutions.

3 And its implementing regulations.