What are Essential Health Benefits (EHB)?

These are services that Qualified Health Plans (QHPs) are required to cover under the Affordable Care Act.   Essential health benefits, as defined in Section 1302(b) of the Patient Protection and Affordable Care Act, will include at least the following general 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 and chronic disease management
  • Pediatric services, including oral and vision care.

Women’s preventive health services were defined in detail via federal regulations published August 1, 2011, requiring broad coverage, without copayments or deductibles of:

  • Annual preventive-care medical visits and exams
  • Contraceptives (products approved by the FDA) – with exemptions for religious employers and a temporary enforcement safe harbor.
  • Mammograms
  • Colonoscopies
  • Blood pressure tests
  • Childhood immunizations
  • Domestic violence screenings for interpersonal and domestic violence should be provided for all women
  • H.I.V. screenings
  • Breast feeding counseling and equipment, including breast pumps at no charge.
  • Gestational diabetes in pregnant women screening
  • DNA tests for HPV as part of cervical cancer screening

Coverage provided for the essential health benefits package will provide bronze, silver, gold, or platinum level of coverage (described below).  A health plan providing the essential health benefits package will be prohibited from imposing an annual cost-sharing limit that exceeds the thresholds applicable to HSA-qualified HDHPs.   Small group health plans providing the essential health benefits package will be prohibited from imposing a deductible greater than $2,000 for self-only coverage, or $4,000 for any other coverage (annually adjusted thereafter).  Such limits will be applied in a manner that will not affect the actuarial value of any health plan, including a bronze level plan (described below). Consistent with the immediate reforms described above, plans providing the essential health benefits package will be prohibited from applying a deductible to preventive health services.

PPACA will require the Secretary to define and periodically update coverage that provides essential health benefits. The Secretary will ensure that the scope of essential health benefits is equal to the scope of benefits under a typical employer-provided health plan (as certified by the Chief Actuary of the Centers for Medicare and Medicaid Services).   A health plan will be allowed to provide benefits in excess of the essential health benefits defined by the Secretary.

However, if a state requires such additional benefits in QHPs, the state must reimburse individuals for the additional costs of those benefits.