Essential Health Benefits
Beginning January 2014, all nongrandfathered individual and small group commercial health plans have to include a comprehensive package of items and services called Essential Health Benefits (EHBs).
Large group plans do not have to provide EHB coverage. However, if a large group plan currently provides coverage of an EHB, annual dollar limits are prohibited. For reference, the minimum EHB categories include:
- 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 dental and vision care.
Actual services vary by state – each state may define EHBs by choosing a benchmark plan.
Plans subject to the EHB requirement must provide benefits that are equal to or greater than the benchmark plan; annual dollar amounts are prohibited.