What are Essential Health Benefits?

Essential Health Benefits (EHBs) are categories of health care services that must be covered by all non-grandfathered* small group (50 or less eligible employees) Qualified Health Plans (QHPs). QHPs are Affordable Care Act-compliant plans that, in addition to covering EHBs, must follow established limits, on cost-sharing. All QHPs are grouped in different metal levels – Platinum, Gold, Silver, Bronze – based on actuarial value, or the percentage of health care costs the plan covers.

EHBs are determined on a state-by-state basis, and at a minimum, they 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
  • Lab services
  • Preventive and wellness services and chronic and disease management
  • Pediatric services, including dental and vision care

Are all employers required to provide EHBs to their employees?
Large group (51 or more eligible employees) fully insured, self-funded and grandfathered plans are not required to cover the 10 EHBs.

* Grandfathered group health plans are those that were in place on March 23, 2010, when the Affordable Care Act (ACA) was enacted. They are exempt from some ACA requirements. However, to maintain grandfathered status, a plan cannot reduce or eliminate benefits, increase employee cost-sharing above certain thresholds, or reduce the employer share of the premium payment. Once a plan loses its grandfathered status, it must comply with all applicable requirements of the law. It is the employer group’s responsibility to determine if the plan is grandfathered.
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