What are essential health benefits?

What are essential health benefits?

Since 2014, the Affordable Care Act (ACA) has required all individual and family health insurance plans to cover ten essential health benefits.

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

All individual and family health insurance plans must cover these essential health benefits without any lifetime or annual limits. However, a plan may require cost-sharing like deductibles, coinsurance, and co-pays.[1]

Note: Essential health benefits are minimum requirements. Some plans may offer additional benefits like dental, vision, and chiropractic care. Also, some states have stricter rules than others.

Defining the ten essential health benefits

Let’s walk through each essential health benefit and what it includes.

1. Ambulatory patient services

This category includes outpatient care you receive without being admitted to a hospital.

2. Emergency services

This category includes care received in an emergency. Your insurance company can't charge you more for getting emergency room services at an out-of-network provider.

3. Hospitalization

This includes treatment you receive in the hospital as part of inpatient care.

4. Maternity and newborn care

This category includes services that care for you and your baby before, during, and shortly after giving birth. 

5. Mental health and substance use disorder services, including behavioral health treatment

This category includes services to treat behavioral health, provide counseling, or provide psychotherapy.

6. Prescription drugs

This category includes coverage of a government-approved prescription drug list. In general, insurance companies must cover one drug from each group.

7. Rehabilitative and habilitative services and devices

This category includes services like physical therapy, occupational therapy, or speech therapy.

8. Laboratory services

This category includes lab tests that diagnose conditions like x-rays and blood tests.

9. Preventive and wellness services and chronic disease management

This category includes services like screenings and vaccines. In general, plans must cover these services without cost-sharing.

10. Pediatric services, including oral and vision care

This includes dental and vision services offered to children through the age of 18. Specifically, plans must cover two routine pediatric dental exams and one annual pediatric eye exam. Adult dental and vision coverage is optional.

Notes:

[1] The exception to this is any service that qualifies as free preventive services, which insurers must cover without cost-sharing.

[2] Here’s a link to the statute on essential health benefits: 42 U.S. Code § 18022.

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