The 10 essential health benefits for health insurance plans

The Affordable Care Act (ACA) mandates that most individual and small group health insurance plans, including those sold on the Health Insurance Marketplaces, cover a set of 10 Essential Health Benefits (EHBs). These benefits are designed to ensure that all plans offer a comprehensive package of items and services. Here’s a brief description of each:

List of The 10 Essential Health Benefit

Ambulatory Patient Services: Outpatient care you receive without being admitted to a hospital.
Emergency Services: Care for conditions that could lead to serious disability or death if not immediately treated, without the need for prior approval.
Hospitalization: Care you receive as an inpatient in a hospital, such as surgery, overnight stays, and other necessary services.
Maternity and Newborn Care: Care before and after your baby is born, ensuring both mother and child receive the necessary healthcare during pregnancy, labor, delivery, and the postnatal period.
Mental Health and Substance Use Disorder Services: Includes behavioral health treatment, counseling, and psychotherapy for mental health issues and substance use disorders.
Prescription Drugs: Medications that are prescribed by a doctor to treat an illness or condition. At least one prescription drug must be covered for each category of drugs.
Rehabilitative and Habilitative Services and Devices: Services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.
Laboratory Services: Testing provided to help a doctor diagnose an injury, illness, or condition, or to monitor the effectiveness of a treatment.
Preventive and Wellness Services and Chronic Disease Management: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Pediatric Services, including Oral and Vision Care: Care for children, including well-child visits, vaccinations, dental care, and vision care.

Uniformity Across States and Populations

While the ACA requires these 10 categories to be covered, the specific services covered within each category can vary by state since states can define their own Essential Health Benefits within these categories. Additionally, the scope and depth of coverage for each benefit can also differ among insurance plans, as long as they meet the minimum standards set by the ACA.

Inclusion in Medicaid and Medicare

Medicaid: The ACA expanded Medicaid to cover all adults with income up to 138% of the federal poverty level (in states that have expanded Medicaid) with a benefits package that includes the Essential Health Benefits. However, Medicaid coverage can vary by state, as states have the flexibility to determine specific coverage within the EHB framework.
Medicare: Medicare is a separate federal program not directly affected by the ACA’s Essential Health Benefits requirements. Medicare has its own set of covered services, which partially overlap with the EHBs but are structured differently. For example, Medicare covers hospital care, doctor visits, and prescription drugs under different parts of the program (Parts A, B, and D), but it does not mandate coverage of all services listed as Essential Health Benefits under the ACA.

Benefits Not Typically Included Among The EHBs

There are certain health care services and benefits that are not explicitly covered under these categories. Here are a few examples of important benefits that might not be included in any specific item on that list or might vary significantly in coverage depending on the state or specific insurance plan:

Adult Dental and Vision Care: The ACA mandates pediatric dental and vision care as part of the EHBs but does not extend this requirement to adults. Adult dental and vision benefits are often offered through separate, optional insurance plans.
Long-term Care: Services that include extended assistance with daily living activities such as bathing, dressing, and eating, often needed by individuals with chronic illnesses, disabilities, or the elderly, are not covered under the ACA’s EHBs. Long-term care is typically provided through Medicaid (for those who qualify) or long-term care insurance policies.
Cosmetic Surgery: Procedures that are not medically necessary, including most cosmetic surgeries, are not covered. However, reconstructive surgery following an injury or to correct a congenital anomaly may be covered.
Infertility Treatments: While some states have mandates for infertility coverage, infertility treatments, including in vitro fertilization (IVF), are not listed as an EHB under the ACA and coverage varies widely by plan and state.
Alternative Medicine: Treatments such as acupuncture and naturopathy are not typically covered as EHBs. Some plans might offer limited coverage for certain alternative therapies, but this is not required under the ACA.
Weight Loss Surgery: Coverage for bariatric surgery or weight loss programs can vary significantly. Some plans may cover these under certain conditions, such as if the patient has severe obesity and other related health conditions, but it’s not mandated as part of the EHBs.
Gender-affirming Care: Coverage for transgender health services, including gender-affirming surgery and hormone therapy, varies by state and plan. Some states have policies requiring these benefits, but they are not explicitly listed as an EHB under the ACA.
Over-the-counter Medications: Even if prescribed by a doctor, over-the-counter medications are generally not covered under the prescription drugs benefit of the ACA’s EHBs.

Plans to Update the EHBs

The Department of Health and Human Services (HHS), which oversees the implementation of the ACA, has the authority to update the EHBs. However, any changes to the EHBs would require a thorough regulatory process, including rule-making, public comments, and potentially legislative actions, depending on the nature of the changes proposed.

The ACA was designed with a degree of flexibility regarding EHBs, allowing states some discretion in how they define the specifics of each benefit category based on a benchmark plan. This means that while the federal government sets the ten broad categories, the detailed coverage within those categories can vary by state. This system was designed to balance comprehensive coverage with the need to keep plans affordable.

There are several areas, though, where there has been public and political interest in expanding coverage, including:

Mental Health Services: Increasing access and reducing barriers to mental health and substance use disorder services, especially in light of the opioid crisis and rising awareness of mental health issues.
Telehealth Services: Expanding coverage for telehealth and remote care services, which has become particularly relevant due to the COVID-19 pandemic.
Maternity and Newborn Care: Enhancing coverage for maternity care, including postpartum care, in response to concerns about maternal mortality and morbidity rates.
Chronic Disease Management and Preventive Services: Strengthening coverage for preventive services and chronic disease management, especially for conditions like diabetes and heart disease.
Prescription Drugs: Addressing the high cost of medications and ensuring access to necessary prescriptions.

Any efforts to update the EHBs would need to consider the impact on insurance premiums, market stability, and overall healthcare costs. Additionally, changes to the EHBs could be influenced by shifts in political leadership, healthcare policy priorities, and legislative actions at both the federal and state levels.

In summary, while the ACA’s Essential Health Benefits provide a baseline for coverage, the specific services and extent of coverage can vary.

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