The Affordable Care Act (ACA) requires that non-grandfathered health plans are required to cover a core package of items and services called “essential health benefits.” This requirements may not apply to self-insured or large group plans.
- Ambulatory patient services;
- Emergency services;
- Maternity and newborn care;
- Mental health and substance use disorder services, including behavioral health treatment;
- Prescription drugs;
- Rehabilitative services and devices;
- Laboratory services;
- Preventive and wellness services and chronic disease management; and
- Pediatric services, including oral and vision care.
The essential health benefits must be equal in scope to benefits offered by a “typical employer health plan.” A final rule issued by the U.S. Department of Health and Human Services defines essential health benefits based on state-specific essential health benefits benchmark plans, and provides that all plans subject to the essential health benefits requirements offer benefits substantially equal to the benefits offered by the benchmark plan.