What are The 10 Essential Health Benefits?

When the Affordable Care Act (ACA) was enacted by 111th Congress and signed into law by President Barack Obama in 2010, it introduced the concept of “Essential Health Benefits” (or EHBs). However, how many of those 10 EHBs can you name? Here’s a  quick summary.

All ACA-qualified plans must cover all of the following 10 Essential Health Benefits:

1. Ambulatory Patient Services (outpatient care you can get without being admitted to a hospital)
2. Emergency Services
3. Hospitalization (including surgery and overnight stays)
4. Pregnancy, Maternity, and Newborn Services
5. Mental Health and Substance Use Disorder Services (including behavioral health treatment, counseling, and psychotherapy)
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 (Adult Dental and Vision coverage are not EHBs.)

A little more about each of the 10 Essential Health Benefits

#1 – Ambulatory Patient Services are the most common form of health care that you and your employees will likely need. This includes outpatient care, such as doctor’s office visits.

#2- Emergency Services are those provided by a hospital emergency room (or emergency department) in the event of a sudden and serious health condition (such as a stroke or heart attack). ACA plans typically do not require a preauthorization for ER visits, although pre-authorization is often required before a covered employee or dependent is admitted to the hospital.

#3- Hospitalization is covered, but plans may include a required co-payment or co-insurance amount (such as 20% if you or your employee has not yet reached your out-of-pocket maximum for covered services.

#4- Pregnancy, Maternity, and Newborn Services: categorized as preventive services, maternity and newborn care are included in all ACA plans at no added costs. Traditionally, prior to the ACA, individual plans have excluded this coverage.

#5- Mental Health and Substance Use Disorder Services: All ACA-qualifying plans must cover behavioral health treatment (such as psychotherapy and counseling), mental and behavioral health inpatient services, and substance use disorder (substance abuse) treatment. Pre-existing mental and behavioral health conditions are covered and spending limit cannot be more restrictive than limits applied to medical and surgical services.

#6- Prescription Drugs were previously an available option that could be added to employer-sponsored health plans at an additional cost. Now, all ACA-qualified individual and small group plans include at least one drug in every category and class in the nation’s official publication of approved medications, U.S. Pharmacopeia. Another important distinction with ACA-compliant plans is that drug costs count toward an insured’s maximum out-of-pocket cap on medical expenses.

#7- Rehabilitative and Habilitative Services include care to help you and your employees relieve pain resulting from injuries, disabilities, and chronic conditions (like multiple sclerosis) – and to help you recover mental and physical skills or regain your ability to speak, walk, or work.

#8- Laboratory Services include preventive screening tests, such as prostate exams and Pap smears, as well as tests ordered by a doctor in diagnosing an illness (although a deductible, co-pays, and/or co-insurance may apply).

#9 – Preventive and Wellness Services, including chronic disease management, have no copay under ACA-qualified plans. In fact, the health care law requires 50 procedures recommended by the U.S. Preventive Services Task Force be covered at no extra cost, including well-woman visits, domestic violence screening, breastfeeding equipment, contraception, blood pressure screening, and cholesterol screening. More information is available here.

#10- Pediatric Services, including health care and some Dental services and Vision care, are also covered for dependent children insured under ACA plans. It’s important to note, however, that adult Dental and Vision care are not Essential Health Benefits. (If you want to include Dental and Vision for your employees, you can add Voluntary or employer-sponsored coverage for those services.)

Fun Facts About the 10 Essential Health Benefits (EHBs)

We are California Different around here, so we like making serious healthcare topics a little more cheerful.

Here are some fun facts about the 10 Essential Health Benefits introduced by the Affordable Care Act (ACA):

• Pediatric Dental and Vision Services
  Did you know your kiddos’ pearly whites and perfect vision are part of the ACA roadmap? This ensures even the youngest members of society can smile brighter and see clearer. Bonus fact? The ACA is one of the first federal policies to highlight the connection between oral health and general health for kids.

• Preventive Services
  Under the ACA, preventive services like vaccinations and screenings are free! That means you can get a flu shot without worrying about breaking the bank. These benefits save lives and money by tackling problems before they get serious.

• Mental Health Parity
  Mental health services are treated just as crucially as physical health care. Plot twist? Prior to the ACA, many insurance plans wouldn’t even cover therapy—but now, stress-busting and self-care are take-center-stage stars.

• Rehab Services
  No, not just for athletes! Physical and occupational therapy is covered under rehabilitation services, ensuring everyone can get back on their feet, recover mobility, or rebuild after an injury. Think of it as personal training, but with a life-changing purpose.

• Prescription Drug Coverage
  Did you know that over 60% of Americans take at least one prescription medication? The ACA ensures prescription drugs are within reach for these millions of people, so lifesaving medications no longer feel like luxury high-priced items.

• Pregnancy Support
  Maternity and newborn care got an all-star upgrade! Fun fact? This coverage also supports breastfeeding moms, ensuring a healthier start for babies (and fewer sleepless nights for parents).

• Lab Services Like Never Before
  Got questions about your health? The ACA’s inclusion of lab services ensures your doctor can provide answers. Maybe not “mad scientist” exciting, but it means smarter decisions about your health.

• Emergency Room Services
  If you need a reason to celebrate, ER visits now come with fewer financial headaches. The ACA made sure “life or death” scenarios didn’t come with life-or-debt consequences.

• Outpatient Care
  You’ve probably used this benefit and didn’t even realize. From minor surgeries to check-ups outside the hospital, outpatient care became a more affordable, accessible health staple.

• Mental Health Meets Substance Use Treatment
  Before the ACA, if a loved one needed substance use treatment, insurance often didn’t cover it. Now, tackling addiction is part of the essential benefits lineup, helping families heal across the country.

Shop and Compare – with Help from a Broker

If you’re interested in knowing more about the employee benefits options available to you, your business, and your employees, a great place to start is to talk with your broker. If you do not currently have an employee benefits broker, we can help you find a CaliforniaChoice broker to speak with about a quote for your business. Contrary to what you might think, broker services are available at no cost to you.

All of the health plans offered through the CaliforniaChoice multi-carrier, employee-choice program are ACA-compliant and include the EHBs described above.