Essential Health Benefits:
A set of health care service categories that must be covered by certain plans, starting in 2014.
The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges (Exchanges), offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified and offered in Exchanges, and all Medicaid state plans must cover these services by 2014. Learn how the Department of Health and Human Services is giving states more flexibility to implement essential health benefits under the Affordable Care Act.
- Fact Sheet: Essential Health Benefits: HHS Informational Bulletin
- Fact Sheet: Individual Market Coverage
- Fact Sheet: Comparing Benefits in Small Group Products and State and Federal Employee Plans
- Fact Sheet: Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage
Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for these services by 2014.
In the fall of 2011, the Department of Health and Human Services launched an effort to collect public comment and hear directly from all Americans who are interested in sharing their thoughts on this important issue. Learn more about this process.