Essential Health Benefits
The Act defines certain categories of benefits as "Essential Health Benefits." The categories of essential health benefits are:
- Ambulatory patient services
- Emergency services
- 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
- Pediatric services, including oral and vision care
Health plans, including self-insured plans, that cover Essential Health Benefits (EHB) may not apply dollar annual or lifetime dollar limits to the benefits. Plans that offer out-of-network benefits covering EHB may not place annual or lifetime limits on the out-of-network benefits as well.
Fully insured plans must use the benchmark plan for the state where the employer is stitused.
Self-funded plans can choose the state they wish to use for their benchmark plan. Self-funded plans may choose not to include one or more of the Essential Health Benefits in their plan.
The benchmark plan provides a guide for which benefits cannot have annual or lifetime limits.
For More Information
- The Basics of Essential Health Benefits(Opens a new window) (PDF)
- Essential Health Benefits Overview(Opens a new window) (PDF)
- Essential Health Benefits FAQ(Opens a new window) (PDF)
- Frequently Asked Questions on Essential Health Benefits Bulletin(Opens a new window) from the Department of Health and Human Services (PDF)
- 2017 Expanded ASO Benchmark Options(Opens a new window) -- essential health benefits comparison grid of
state and federal benchmark plans
- Essential Health Benefits Bulletin(Opens a new window) from the Department of Health and Human Services, Dec. 16, 2011 (PDF)
- Habilitative Services Coverage Determination Guideline (CDG)(Opens a new window) (Available on January 1, 2016)
- Rehabilitative Services Coverage Determination Guideline (CDG)(Opens a new window) (Available on January 1, 2016)