The ACA ensures that health plan designs sold to individuals and small employers — both inside and outside of Marketplaces — will cover a set of minimum items and services, known as essential health benefits or EHBs. This requirement began in 2014 as policies renewed to 2014 plans, or new 2014 policies were issued.
EHBs include the following general categories, which may vary slightly by state:
- Ambulatory patient services, which includes doctor office visits and other same-day outpatient care
- Emergency services
- Hospitalizations
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
- Chiropractic care
Health insurers will not be able to sell any individual or small employer plan designs that don’t include these EHBs at a minimum.*
Before the new healthcare law was enacted, many health insurers set dollar caps on how much they would pay for services: either an annual dollar limit on a specific type of care, or a lifetime dollar maximum on a service or treatment. Once the limit was reached, the member was responsible for paying the full cost of any additional care.
In addition to requiring coverage of these benefits, the ACA prohibits lifetime dollar limits on all EHBs. Annual dollar limits on EHBs are being phased out of all individual and group designs and will be prohibited altogether as policies renew on or after January 1, 2014. Please note that health plan designs may still place lifetime and annual limits on services not considered essential. For example, a plan cannot limit coverage of preventive care services (an EHB) to a specific dollar amount, but it may limit acupuncture benefits (not considered essential) to an annual or lifetime maximum dollar amount.
*Health insurers may exclude pediatric dental benefits from their medical plan designs if they offer pediatric dental separately as a stand-alone dental plan.