Essential Health Benefits (EHB)

Essential Health Benefits (EHB) are the 10 categories of healthcare services that the Affordable Care Act requires every Marketplace plan to cover. Before the ACA, individual insurance commonly excluded maternity, mental health, or prescription drugs. The EHB rule closed those gaps. Every plan sold on HealthCare.gov, regardless of metal tier or carrier, must cover all 10 categories.

The 10 categories

Every ACA-compliant plan must cover services in each of these 10 areas:

1. Ambulatory patient services (outpatient care without being admitted to a hospital)
2. Emergency services
3. Hospitalization (including surgery and overnight stays)
4. Pregnancy, maternity, and newborn care (before and after birth)
5. Mental health and substance use disorder services (including behavioral health treatment)
6. Prescription drugs
7. Rehabilitative and habilitative services and devices (helping people recover or maintain skills after injury, disability, or chronic condition)
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care for children

A plan that excludes any of these 10 is not a Qualified Health Plan and cannot be sold on the Marketplace.

Coverage is required, but specifics vary

The ACA requires that the 10 categories be covered, but each state picks a benchmark plan that defines exactly what services and limits qualify within each category. Two Silver plans in the same metal tier can cover the same 10 categories but differ on:

• Which specific drugs are on the formulary
• How many physical therapy visits per year are covered
• Whether bariatric surgery is included
• Adult dental and vision (not required by federal EHB rules)

What is not required

Federal EHB rules do not require:

• Adult dental (some plans add it as a separate rider)
• Adult vision (same)
• Long-term care (nursing home, custodial care)
• Cosmetic surgery
• Weight-loss surgery in every state (depends on benchmark)

Pediatric dental and vision are required for children under 19.

Example

A 35-year-old single mom in Florida shopping a Silver Marketplace plan can be sure her plan covers her son’s pediatric dental cleanings, her own annual mammogram (preventive), a delivery if she has another child, prescription drugs for her thyroid condition, and 30 days of inpatient mental health if she needs it. She does not have to read the fine print to confirm these are covered. They are required by federal law.

Related terms

• Qualified Health Plan (QHP)
• Preventive Care
• Metal Tiers
• Formulary

Run the calculator to see Marketplace plans that cover all 10 EHB categories in your county.