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.
For more information
- The basics of essential health benefits (pdf)
- Essential health benefits overview (pdf)
- Essential health benefits FAQ (pdf)
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Frequently asked questions on essential health benefits bulletin (pdf)
from the Department of Health and Human Services
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2017 expanded aso benchmark options (pdf)
Essential health benefits comparison grid of state and federal benchmark plans
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Habilitative services coverage determination guideline
Available on January 1, 2016
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Rehabilitative services coverage determination guideline
Available on January 1, 2016