Essential Benefits

The Act defines certain categories of benefits as “Essential Health Benefits.”

The categories of essential health benefits are:

  • 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

    Five Key Things to Know About Essential Health Benefits

    1. EHB includes the 10 mandated categories, with children’s dental and vision the only new
    category typically not covered by most medical plans today. State definitions of
    EHB will vary and may require product adjustments.

    2. Most Small Group (insured) and Individual policies will have to cover all EHB categories in
    2014, while Large Group (insured and ASO) and all grandfathered plans are not required to
    cover EHB.

    3. Although not all plans have to cover EHB, all plans that do contain any EHB must remove
    annual dollar and lifetime dollar limits for those services, including Large Group (insured
    and ASO). Individual grandfathered plans must remove lifetime dollar limits, but not annual
    dollar limits. With respect to EHB, we already removed lifetime dollar limits and annual
    dollar limits in 2010. We will continue to make any adjustments required as a result of each
    state’s determination of EHB.

    4. The pricing impact of EHB is uncertain because it will depend on state-specific EHB
    definitions and how much flexibility federal rules will permit.

    5. “Habilitative services” are not typically covered explicitly and not yet defined by the states or
    the Department of Health and Human Services, but are generally provided at parity with
    rehabilitative benefits.

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