Essential Health Benefits


Mandatory Coverage for Health Care Services

The Affordable Care Act introduced a new rule for individual health insurance, requiring plans to cover at least ten categories of care, called essential health benefits (EHBs).


Starting Jan. 1, 2014, all new, non-grandfathered individual and small group policies — sold since March 2010 — must provide certain services that fall under these categories for all members.


The final rule on EHBs was released Feb. 20, 2013, and like much of the legislation, is fairly long at 149 pages.

Although this rule seems to require individual insurers to provide good coverage, the lengthy fine print neglects to specify which benefits may be covered under these broad categories. According to the Department of Health and Human Services (HHS), insurers and states still have some freedoms within these mandates, which can be somewhat misleading to people with conditions and disabilities.


When presented as a whole, the essential benefits list sounds like a comprehensive health plan should, including several services that don’t typically get covered. However, the HHS prefaced the finalized regulation by saying they will determine health plan discrimination based on analytic tools, not simply on denying people coverage.


Essential health benefits must be covered in certain individual plans sold on and off the health insurance exchange.


The 10 Categories of Coverage

The following types of care must be covered by each private health plan on the individual market in each state.


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


Benchmark Plans

The Model Health Insurance Plan

The concept behind essential health benefits is for individual insurers to offer coverage akin to an employer plan. In order to regulate health plans and ensure that EHBs are equivalent to the average group plan, the government allows states to select from a benchmark plan specific to that state.

Benchmark plans are already established in the state, and are known to cover a variety of benefits for many members. Once the state chooses their archetypal health insurance plan, they will have to offer similar coverage offered by that plan.


If the benchmark plan does not include one of the 10 essential benefit categories, it will have to offer it in some regard and will be addressed by the state’s health and human services department.

Benchmark plans will be selected according to a few different options:

  • The state’s largest private small group plan based on enrollment
  • Any of the top three state employee health benefit plans with the highest membership
  • Any of the top three Federal Employee Health Benefits Program (FEHBP) with the highest membership
  • The state’s largest commercial HMO (not including Medicaid enrollment)


Essential Health Benefits FYI


Don’t expect your Obamacare health plan to cover everything.

These ten categories are helpful, yet the legislation doesn’t specify any particular services. Congress gave insurers the freedom to design health plans for exchanges and the traditional market, which means they may cover certain types of care but not others within the same category.

For instance, a marketplace health plan may cover behavioral health care services like psychotherapy, but not more complex ones such as applied behavioral analysis therapy, a common autism treatment.

The ACA limits insurers from discriminating against health conditions, but due to the loose nature of the EHB rule, health plans may not include coverage for everything you need for a certain medical problem. If your state has a high risk pool, it may be a better option for covering your condition.


Always read your health plan documents before receiving care.

The final rule for essential health benefits is very vague, and doesn’t require health insurers to cover each type of service under each of the ten categories. A more accurate picture of what your health plan pays for can be found in the documents you received with your plan, such as the schedule of benefits.

Read through this file or call your insurer before going to the doctor, just so you know whether to bring cash or an insurance card to the office. (Though technically you should always have your insurance card).


Your health plan cannot exclude benefits based on discrimination.

The essential health benefit rule makes it clear that insurers are unable to discriminate against any policyholder for:

  • Health status
  • Race
  • Color
  • National origin
  • Age
  • Sex
  • Gender identity
  • Sexual orientation


To view health plans in your area and see what they cover, get your free health insurance quote.