ACA – Essential Health Benefits



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.

  1. Ambulatory patient services;
  2. Emergency services;
  3. Hospitalization;
  4. Maternity and newborn care;
  5. Mental health and substance use disorder services, including behavioral health treatment;
  6. Prescription drugs;
  7. Rehabilitative services and devices;
  8. Laboratory services;
  9. Preventive and wellness services and chronic disease management; and
  10. 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.

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