Choice Stories

February 6, 2018

ACA Essential Health Benefits – What Do They Include?

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 summary.

All ACA-qualified plans must cover all of the following:

  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.)

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.

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.  

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.

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.

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.

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.

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.

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).

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.

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.)


What to Know About Potential AHP Coverage

The White House proposal to expand the use of Association Health Plans (AHPs), where small business owners and their employees could join others in an association to purchase health insurance, could result in the elimination of coverage for some services now considered EHBs. Because association plans would be classified as Large Group plans, they would not be subject to the current ACA guidelines. Critics of AHPs have voiced concern about the potential elimination of benefits under the next generation of plans; however, it’s not yet known what form the plans could take. The “public comment period” is now underway and federal agencies and Congress will likely not adopt final rules until later this year or early next year.


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.


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