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Essential Health Benefits

With the Affordable Care Act beginning in January 2014, fully insured small group and individual health plans on and off the Exchange/Marketplace must cover essential health benefits (EHB).

Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.

Essential health benefits under the Patient Protection and Affordable Care Act will include the following general categories:

  • These essential health benefits include at least the following items and services:
  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services including oral and vision care

According to the Affordable Care Act, plans of all sizes that cover benefits designated as Essential Health Benefits, including self-funded plans, must cover these benefits with no annual limits or lifetime maximums.

Footnote: This is a brief overview of Essential Health Benefits required by the Affordable Care Act. You should read thoroughly and understand the benefits offered before purchasing any insurance policy.