What are Essential Health Benefits?
Health Insurance | 15 Nov 2022
There are 10 categories of services — called essential health benefits — that all private health insurance plans offered in the Health Insurance Marketplace® must cover.
Essential Health Benefits are minimum requirements for all Health Insurance Marketplace® plans, available at HealthCare.gov. A set of 10 categories that are classified as essential health benefits must be covered under health insurance plans through the Affordable Care Act (ACA). These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services.
Plans must offer dental coverage for children — dental benefits for adults are optional.
You can see exactly what each plan offers when you compare plans.
Marketplace Required Essential Health Benefits
These are the 10 categories that are classified as Essential Health Benefits (EHB) and must be covered under a health insurance plan through the Affordable Care Act (ACA) as a benchmark. When shopping for individual or public coverage, these standard EHBs, at a minimum, cover the following services:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription 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
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
If you are unsure of what your health requirements in the coming year might be, talk to your doctor.
Additional Coverage Benefits
Plans must also include the following benefits:
- Birth control coverage
- Breastfeeding coverage
Plans may offer additional benefits, including:
- Dental coverage
- Vision coverage
- Medical management programs (for specific needs like weight management, back pain, and diabetes)
Kansas Essential Health Benefits
Generally, all states provide the same essential health benefits, but some states require insurers to cover additional services and procedures. Even within the same state, there can be small differences.
When you compare plans in the Marketplace, you’ll see the specific benefits each plan offers. There are 128 total plans available in Kansas for 2022. See the 2023 Kansas Insurance Plans Brief (PDF).
Essential Health Benefits FAQs
FAQs about doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more.
What if I need treatment that is not an essential health benefit?
Plans may cover other services. When you compare plans, you’ll see more detailed information about what’s covered. If you want to find out if a particular service is covered, call the plan or contact Cover Kansas to help you get answers.
Are there deductibles and copays for essential health benefits?
All Marketplace plans have deductibles, copayments, and other out-of-pocket costs that apply to most covered services. Some preventive services are free, and some plans cover other services without out-of-pocket costs.
Are abortions considered essential health benefits?
Sometimes, and plans may have different restrictions. Some offer no coverage or coverage with restrictions. In some cases abortion services cannot be paid for with federal dollars (these are known as “non-Hyde” abortion services). You should contact each plan you are interested in to learn about its abortion coverage.
Do essential health benefits cover mental health?
All Marketplace plans cover mental health and substance abuse services as essential health benefits.
Get Answers About Essential Health Benefits
Contact a Certified Health Navigator who can help answer all your questions about essential health benefits and choosing health coverage from the Marketplace that best meets your needs.
Call us at (866) 826-8375 or find a navigator near you.