What Are Essential Health Benefits?
Essential Health Benefits (EHB) are a set of 10 healthcare service categories that the Affordable Care Act requires all qualified health plans to cover. These benefits ensure that individuals and families have access to comprehensive healthcare coverage, regardless of which plan they purchase.
Before the ACA, insurance companies could sell plans that didn't cover important services like maternity care, prescription drugs, or mental health treatment. The EHB requirement eliminates these gaps in coverage.
The 10 Essential Health Benefit Categories
Ambulatory Patient Services
Outpatient care you receive without being admitted to a hospital, including doctor visits and outpatient procedures.
Emergency Services
Emergency room visits, ambulance services, and urgent care—without requiring prior authorization.
Hospitalization
Inpatient care including surgery, overnight stays, and facility costs when you're admitted to a hospital.
Maternity & Newborn Care
Pregnancy, childbirth, and newborn care including prenatal visits, delivery, and postpartum care.
Mental Health & Substance Use Disorder Services
Behavioral health treatment including counseling, psychotherapy, and substance abuse treatment programs.
Prescription Drugs
Coverage for prescription medications, though specific drugs covered vary by plan formulary.
Rehabilitative Services & Devices
Physical therapy, occupational therapy, speech therapy, and medical devices to help with recovery.
Laboratory Services
Blood tests, urinalysis, diagnostic testing, and pathology services ordered by your doctor.
Preventive & Wellness Services
Screenings, vaccines, and checkups covered at 100% with no copay when using in-network providers.
Pediatric Services
Dental and vision care for children, including routine exams, cleanings, and glasses.
Why Essential Health Benefits Matter
The EHB requirement ensures that all ACA marketplace plans provide comprehensive coverage. Before the ACA, insurance companies could exclude entire categories of care, leaving consumers with significant gaps in coverage.
Key Advantage
You can compare plans based on cost and network, knowing that all plans cover the same essential categories of care.
No Lifetime or Annual Limits
In addition to requiring coverage of these 10 categories, the ACA prohibits lifetime and annual dollar limits on Essential Health Benefits. This protects you from catastrophic medical bills if you have a serious illness or chronic condition.
How Plans Differ Within EHB Requirements
While all qualified health plans must cover the 10 EHB categories, insurers have flexibility in how they implement coverage:
- Provider Networks: Plans can use different doctor and hospital networks
- Prescription Drug Formularies: The specific medications covered can vary
- Cost-Sharing: Deductibles, copays, and coinsurance amounts differ by plan
- Prior Authorization: Requirements for pre-approval of certain services vary
- Referral Requirements: Some plans require referrals to see specialists
Comparing Plans With EHB in Mind
When comparing ACA marketplace plans, you can focus on these factors since EHB coverage is guaranteed:
Plans Exempt from EHB Requirements
Not all health insurance plans are required to cover Essential Health Benefits:
- Grandfathered Plans: Plans that existed before March 23, 2010 and haven't made significant changes
- Short-Term Health Insurance: Temporary plans designed for coverage gaps (not ACA-compliant)
- Health Care Sharing Ministries: Not insurance and not required to cover EHB
- Catastrophic Plans: Cover EHB but have very high deductibles and are only for specific populations
Get Expert Help Choosing Your Plan
Understanding Essential Health Benefits is just one piece of selecting the right health insurance plan. Larry Fisackerly can help you compare plans, understand how EHB applies to your specific healthcare needs, and find the best coverage at the best price.
Need Help Understanding Your Options?
With 30+ years of experience, I can explain how Essential Health Benefits apply to your situation and help you compare plans from all major Texas carriers.