Under the Affordable Care Act (ACA), all fully insured small group and individual health plans—whether on or off the Exchange/Marketplace—must cover Essential Health Benefits (EHB).
Essential health benefits are minimum coverage requirements for Marketplace plans. While plans may offer additional coverage, they must include these 10 categories of services:
✔ Ambulatory Patient Services – Outpatient care you receive without hospital admission.
✔ Emergency Services – Emergency room visits and urgent medical needs.
✔ Hospitalization – Inpatient care, including surgeries and overnight stays.
✔ Maternity & Newborn Care – Prenatal, delivery, and postnatal care.
✔ Mental Health & Substance Use Disorder Services – Includes therapy, counseling, and behavioral health treatment.
✔ Prescription Drugs – Coverage for essential medications.
✔ Rehabilitative & Habilitative Services and Devices – Helps individuals recover or gain mental and physical skills due to injury, disability, or chronic conditions.
✔ Laboratory Services – Includes diagnostic tests and lab screenings.
✔ Preventive & Wellness Services & Chronic Disease Management – Covers preventive care, screenings, and chronic disease management programs.
✔ Pediatric Services (Including Oral & Vision Care) – Ensures comprehensive coverage for children’s health needs.
The ACA mandates that plans covering Essential Health Benefits cannot impose annual or lifetime limits on these services.
This is a brief overview of the Essential Health Benefits required by law. Before purchasing a health plan, review the detailed benefits to ensure it meets your needs.
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