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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.

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.