What Are Essential Health Benefits?

One of the new provisions in the Affordable Care Act creates a set of criteria for the health care services that will be offered within new insurance plans. These criteria are called Essential Health Benefits, or EHB, and they are meant to help ensure that individuals have access to high quality, comprehensive health services.

Plans will be required to offer coverage in each of the ten EHB categories:

  1. Ambulatory patient services (such as hospital visits)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services (including oral and vision care)
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These categories were established by the Affordable Care Act, which then requested that the Department of Health and Human Services (HHS) further define the standards. HHS has issued initial guidance which provides states with some flexibility in how they established EHB standards. As states move forward to open health insurance exchange marketplaces (you can read more about exchanges in this post), they will choose a plan by the end of September to act as a "benchmark"--the plan that all other plans must be equal to or better than--and the way that the benchmark plan covers the EHB categories will guide how other plans cover those categories as well. In other words, plans will be required to offer coverage of the same services, but the level of coverage within each service category may vary from state to state.

We are interested to see what further guidelines the Department of Health and Human Services issues on the topic of EHB, and we'll be encouraging policymakers to take care that the Essential Health Benefits coverage in their state is high-quality and provides patients with comprehensive access to the medicines and treatments they need.

Later this week, we will take a look at how Essential Health Benefits will impact prescription drug coverage. Make sure you're following us on Facebook and Twitter to find out when our latest post is published.