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.
  • 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 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.