Essential health benefits
Ten categories of health care services that ACA-compliant individual and small-group plans must cover.
Updated
Essential health benefits are ten categories of services that non-grandfathered health plans in the individual and small-group markets must cover under the Affordable Care Act. The categories include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness and chronic disease management, and pediatric services (including oral and vision care).
Specific coverage within each category can vary by plan and state benchmark, but all ten categories must be represented in covered benefits.
In practice
Claims for services that fall within essential health benefit categories are processed under plan benefits without annual or lifetime dollar limits on covered essential health benefits. Billing teams should still verify specific plan coverage and medical necessity, since category inclusion does not guarantee coverage of every service or code.
Commonly confused with
- Covered service: A covered service is any service the plan reimburses; essential health benefits are the ACA-required minimum categories for compliant plans.