Essential Health Benefits Insurance Requirements and Coverage

The Affordable Care Act requires health insurance plans to cover essential health benefits, which include a range of services that are considered essential for maintaining health and well-being.

These benefits must be covered without cost-sharing, such as copays or deductibles, for individuals under the age of 19. This means that children under 19 can get these services without paying a dime out of pocket.

Preventive services like routine check-ups, vaccinations, and screenings are also essential health benefits that must be covered without cost-sharing. This includes services like mammograms and colonoscopies.

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Essential health benefits are the minimum services that must be covered by health insurance plans.

These benefits include preventive care services, such as routine check-ups and screenings.

Preventive care services are designed to help prevent or detect health problems early on.

For example, routine check-ups can help identify health issues before they become serious.

Mental health and substance use disorder services are also essential health benefits.

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These services include counseling and therapy sessions.

They can help individuals manage mental health conditions and avoid substance abuse.

Pediatric services, such as well-child visits and vaccinations, are also essential health benefits.

These services are designed to help ensure the health and well-being of children.

Additionally, maternity and newborn care services are essential health benefits.

These services include prenatal care, childbirth services, and postpartum care.

Insurance companies must cover at least one service within each of the 10 EHB categories, but not all services or treatments within a category need to be covered. This means you may still have to pay something for a covered benefit.

Having a "covered" benefit doesn't necessarily mean you won't pay for care. An insurance company must include covered benefits in their cost-sharing, so you will probably still pay some of the cost. For example, if your plan covers ambulance rides, it doesn't mean all ambulance rides are free, and you may still have to pay some of the cost.

Insurance companies cannot put annual or lifetime limits on how much you spend on any of the essential health benefits.

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An issuer providing Essential Health Benefits (EHB) must comply with the requirements of § 156.200(e) of this subchapter.

No health insurance plan sold through an exchange can deny you coverage or charge you more because you have a pre-existing condition. Examples of pre-existing conditions include asthma, diabetes, and cancer.

Starting on the first day of your coverage, the insurer also cannot refuse to cover your treatment for a pre-existing condition.

An issuer does not provide EHB if its benefit design discriminates based on an individual's health conditions, including pre-existing conditions.

You're protected from discrimination based on your health conditions, and insurers must provide coverage for your treatment starting from the first day of your coverage.

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Having a service covered by your insurance plan doesn't necessarily mean you won't pay anything. According to the Affordable Care Act, insurance companies must include covered benefits in their cost-sharing, so you'll still have to pay some of the cost.

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For example, if your plan covers ambulance rides, it doesn't mean all ambulance rides are free. You might still have to pay out-of-pocket for certain situations or if you use an out-of-network ambulance.

Insurance companies are also prohibited from putting annual or lifetime limits on how much you spend on any of the essential health benefits.

Here's a breakdown of what you might expect to pay for certain services:

Keep in mind that these are just general examples, and your specific plan and situation may vary. Always review your plan documents and talk to your insurance provider to understand what's covered and what you might pay.

Emergency care is one of the most costly medical expenses, and certain situations can cost a lot even with insurance.

Your insurance will cover care for a life-threatening situation, such as a heart attack or stroke, and for situations where you could lose a limb without immediate medical attention.

Emergency rooms are designed to handle life-threatening emergencies, but if your circumstances don't meet the exact definition of an emergency, you could end up with medical bills totaling thousands of dollars.

If you go to the emergency room and your insurance deems your situation not an emergency, you may be on the hook to pay for the entire bill, even if doctors recommend you stay in the hospital.

Using an out-of-network hospital or doctor can potentially add $5,000 or more to your medical bill, so it's essential to understand how your insurance defines emergency services.

If you went to the hospital via an ambulance but your insurance deems you could have gotten to the hospital through other means, you may be responsible for paying for the ambulance ride.

State Required benefits are a crucial aspect of Coverage Requirements. They are considered to include only State requirements for issuers to cover specific care, treatment, or services.

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State requirements for reimbursement of specific health care professionals who render a covered service within their scope of practice are not considered State Required benefits. This means that if a State requires a certain type of healthcare provider to be reimbursed for their services, it doesn't necessarily mean that service is an Essential Health Benefit.

State Required benefits do not include dependent mandates, which require defining dependents in a specific manner or covering dependents under certain circumstances. This means that if a State requires coverage for newborns or adopted children, for example, that's not considered a State Required benefit.

State anti-discrimination requirements relating to service delivery method are also not considered State Required benefits. This means that if a State requires that certain services be delivered in a specific way, such as through telemedicine, that's not considered a State Required benefit.

A benefit required by State action taking place on or before December 31, 2011, is considered an Essential Health Benefit. This means that if a State required a certain benefit before 2012, it's still considered an EHB today.

A benefit required by State action for purposes of compliance with Federal requirements is also considered an Essential Health Benefit. This means that if a State required a certain benefit in order to comply with Federal laws, it's still considered an EHB.

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Essential health benefits are a crucial part of health insurance plans, ensuring that individuals have access to comprehensive coverage for various medical services.

All health plans must cover ambulatory patient services, also known as outpatient services, which include doctor visits, surgeries, and other treatments that don't require hospitalization.

Insurance companies must cover emergency services, including emergency room visits, ambulance rides, and other urgent care needs.

Pregnancy, maternity, and newborn care are also essential health benefits, which means insurance companies must cover care during pregnancy, as well as before and after childbirth.

Maternity care and newborn care must be covered, and insurance companies cannot deny coverage or charge women higher prices.

Women can rest assured knowing that they will have maternity coverage when they become pregnant, as it is considered a preventive care service.

Prescription drugs are also covered under essential health benefits, which means insurance companies must cover medications for various medical conditions.

Lab services, including diagnostic tests, are also essential health benefits, which means insurance companies must cover lab services beyond just preventive screening tests.

Habilitative services, which help patients acquire, maintain, or improve skills necessary for daily functioning, are also covered under essential health benefits.

Mental health and substance use disorder services, including behavioral health treatment, are essential health benefits, which means insurance companies must cover these services.

Rehabilitative services, which help patients regain skills or function after an injury or illness, are also covered under essential health benefits.

Hospitalization, including surgery, overnight stays, and other care, is also an essential health benefit that must be covered by insurance companies.

Here is a breakdown of the 10 essential health benefits:

In addition to the 10 categories of health benefits, plans must also include a few other benefits. These benefits are just as essential to our well-being.

A plan must cover mental health and substance use disorder services, including counseling and therapy. This is crucial for maintaining good mental health and preventing addiction.

Plans must also cover habilitative services, which are services that help us learn or recover skills. This can include physical, occupational, or speech therapy.

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Other plans must cover a range of benefits beyond the 10 categories of health benefits.

In addition to the required categories, plans must also include a few other benefits. These include prescription drug coverage that meets specific standards.

Plans subject to EHB requirements must cover at least the same number of prescription drugs in every category and class as the State's EHB-benchmark plan, or one drug in every category and class, whichever is greater.

The USP Medicare Model Guidelines (MMG) is used to classify prescription drugs, and plans must cover at least the same number of drugs in each category and class as the EHB-benchmark plan.

If a prescription drug category has no coverage in the EHB-benchmark plan, plans must cover at least one drug in that category and/or class.

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For stand-alone dental plans inside the Exchange, there's a specific rule about annual cost-sharing limits. These plans can't charge more than $350 for one covered child and $700 for two or more covered children.

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The annual dollar limit for one covered child is adjusted each year based on the consumer price index for dental services. This increase is calculated by comparing the consumer price index for dental services two years prior to the plan year to the consumer price index for dental services in 2016.

For plan years starting after 2017, the dollar limit for one covered child is increased by the percent increase in the consumer price index for dental services. This increase is rounded down to the next lowest multiple of $25 if it's not a multiple of $25.

The dollar limit for two or more covered children is twice the dollar limit for one child, making it $700. This limit is also adjusted annually based on the consumer price index for dental services.

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A plan may not exclude coverage of an EHB category, regardless of whether such limits exist in the EHB-benchmark plan, with the exception of pediatric services.

Plans subject to EHB requirements must cover at least the same number of prescription drugs in every category and class as the EHB-benchmark plan, or one drug in every category and class, whichever is greater.

The USP Medicare Model Guidelines are used to classify prescription drugs, and CMS updates state EHB-benchmark plans to reflect the most up-to-date version of these guidelines available.

If the EHB-benchmark plan does not include any coverage in a USP category and/or class, EHB plans must cover at least one drug in that category and/or class.

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For plan years 2020 and beyond, the Essential Health Benefits (EHB) benchmark plan selection process was simplified. CMS provided states with three options to select their EHB-benchmark plan, including selecting the EHB-benchmark plan that another state used for the 2017 plan year, replacing one or more categories of EHBs with the same category or categories of EHB from another state's EHB-benchmark plan, or otherwise selecting a set of benefits that would become the state's EHB-benchmark plan.

States must submit several documents to select a new EHB-benchmark plan, including the EHB State Confirmation Template, Actuarial Certification/Report, EHB-Benchmark Plan Document, EHB-Benchmark Summary Chart Template, and Formulary Drug List Template, if applicable.

The Final 2025 HHS Notice of Benefits and Payment Parameters consolidated the three options for states to change EHB-benchmark plans, effective for plan years beginning on or after January 1, 2026. Under this new process, states may select a new EHB-benchmark plan by choosing a set of benefits that would become the state's EHB-benchmark plan.

Here are the required documents for states to submit when selecting a new EHB-benchmark plan for plan years beginning on or after January 1, 2026:

Note that states that opted not to exercise this flexibility continue to use the same EHB-benchmark plan in effect since plan year 2017.

The cost of health insurance can be a real sticker shock. Your plan's metal tier determines how much you'll pay for in-network care.

You'll also need to consider the type of plan you have, such as HMO, PPO, or EPO, which can affect your in-network and out-of-network costs. Seeing a specialist without a primary care physician referral can cost more with an HMO.

Reaching your deductible is another factor that affects your costs. After you've met your deductible, your insurance starts to cover some costs.

You'll also need to keep an eye on your out-of-pocket maximum, after which your insurance covers all costs for the remainder of the calendar year.

To determine if a plan provides minimum value, an employer-sponsored plan must have a percentage of total allowed costs of benefits that is greater than or equal to 60 percent. This percentage must be calculated using one of four acceptable methods.

The MV Calculator made available by HHS and the Internal Revenue Service is one such method, but the result may be modified under certain rules. Alternatively, a plan may use a safe harbor established by HHS and the Internal Revenue Service or seek certification by an actuary to determine minimum value.

A plan in the small group market that meets any of the levels of coverage described in § 156.140 of this subpart automatically satisfies minimum value.

A multi-state plan must meet benchmark standards set by the U.S. Office of Personnel Management.

To determine EHB, a multi-state plan must include preventive health services described in § 147.130 of this subchapter. This is a requirement for all multi-state plans.

Notice and Comment is a crucial step in the review process. It's a chance for the public to weigh in on proposed changes to a rule or regulation.

The notice period can last anywhere from 30 to 60 days, depending on the complexity of the proposal. This allows for a thorough review by stakeholders and the public.

Notice and Comment is a public process, which means that anyone can submit comments on a proposal. Comments can be submitted online, by mail, or in person.

In some cases, a public hearing may be held to gather input from the public. This can be a valuable opportunity for stakeholders to ask questions and express their concerns.

The agency must consider all comments received during the notice and comment period before making a final decision. This ensures that the final rule or regulation is fair and effective.

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Judicial review is a crucial step in the process of resolving disputes. It's a way for a higher court to review the decisions made by lower courts or administrative bodies.

A judicial review can occur in various situations, such as when a party disagrees with a decision made by a lower court or when a government agency's decision is challenged.

Judicial review is not the same as an appeal, although the two terms are often used interchangeably. In a judicial review, the court examines the decision-making process and the law that was applied, rather than just the facts of the case.

The court's main goal in a judicial review is to determine whether the decision-maker acted reasonably and within their powers.

Some essential health benefits have limitations or exclusions.

Pre-existing conditions are generally not covered by essential health benefits. This means that if you have a pre-existing condition, such as diabetes or asthma, you may not be able to get coverage for related expenses, like doctor visits or medication.

Certain services, like cosmetic surgery or fertility treatments, are also not typically covered. This can be a concern for people who need these services, but it's essential to understand what is and isn't covered under essential health benefits.

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Process-Based Concerns often arise from a lack of clear expectations or unclear roles and responsibilities.

In the absence of a clear process, it can be challenging to determine who is responsible for what, leading to confusion and delays.

For example, the article highlights the case of a project where the team leader was unclear about their role, resulting in a 30% increase in project duration.

Inadequate communication and a lack of transparency can also contribute to process-based concerns.

According to the article, a team that implemented regular check-ins and progress updates reduced their project duration by 25%.

A poorly defined process can also lead to inconsistent results and a lack of accountability.

In one case study, the article notes that a team that lacked a clear process for reviewing and revising their work experienced a 40% decrease in quality.

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Excluded benefits are a crucial aspect to understand when it comes to Essential Health Benefits (EHB). Routine non-pediatric dental services are excluded from EHB for plan years beginning on or before January 1, 2026.

Long-term/custodial nursing home care benefits are also excluded from EHB. This means that plans may not be required to cover these services as part of the EHB requirement.

Routine non-pediatric eye exam services are another benefit that is excluded from EHB. This exclusion applies to all plan years, regardless of the start date.

Non-medically necessary orthodontia is also excluded from EHB, and this exclusion is consistent across all plan years. This means that plans may not be required to cover these services as part of the EHB requirement.

Abortion services are not required to be covered as part of the EHB, even if the EHB-benchmark plan includes them. However, this does not prevent issuers from choosing to cover abortion services or states from requiring or prohibiting them under state law.

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If you're looking for information on Essential Health Benefits Benchmark Plans, you can find it on the provided website.

The website offers a way to view the current EHB-benchmark plan for a particular State by selecting the State from a list.

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You can also find information on State-required benefits, which are listed separately.

The website provides ZIP files for EHB Benchmark Plan Information for specific years, including 2017-2025 and 2026.

State-required benefits and EHB Benchmark Plan Information are available for different plan years, including 2017-2020 and 2021-2026.

Here's a list of available information on the website:

Eliminating certain groups from our society can have severe consequences, including a loss of unique perspectives and skills that can hinder our collective progress.

The exclusion of individuals with disabilities can lead to a lack of accessibility in public spaces, making it difficult for them to participate in daily activities.

Research has shown that excluding certain groups can also result in a decrease in economic productivity, as their skills and talents are not being utilized.

The loss of cultural diversity that comes with excluding certain groups can lead to a homogenization of society, making it less interesting and less resilient.

The exclusion of minority groups can also lead to a lack of representation in positions of power, making it difficult for them to have a voice in decision-making processes.

This can create a cycle of inequality, where those in power continue to exclude and marginalize certain groups, further entrenching their own privilege.