Essential Health Benefits

Summary

The Act defines certain categories of benefits as "Essential Health Benefits." The categories of essential health benefits are:

  • 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
  • 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.

Benchmark plans

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.

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