The Act defines certain categories of benefits as “Essential Health Benefits.”
The categories of essential health benefits are:
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
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