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What are the Essential Health Benefits?

The law requires health plans offer comprehensive benefits and services beginning in 2014, known as Essential Health Benefits.

These benefits are only required on plans offered to small group employers and individuals/families that purchase their own health insurance. Plans offered by large group employers are not required to cover the essential health benefits, but if they do, they may not impose annual or lifetime dollar limits on them.

Essential Health Benefits must include items and services for these 10 categories:

  • 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 can’t impose annual or lifetime dollar limits on the Essential Health Benefits. Depending on the type of plan you have, services associated with essential health benefits may still require you to pay copays, co-insurance and deductibles.

Your plan may still have an annual dollar limit and/or a lifetime dollar limit on spending for health care services that are not considered Essential Health Benefits.