Essential Health Benefits

The Affordable Care Act ensures that health plans offered in the individual and small group markets, both inside and outside of the Exchanges, offer a comprehensive package of items and services known as essential health benefits. Insurance policies must cover these benefits in order to be certified and offered in the Exchanges, and all Medicaid/Medi-Cal state plans must cover these services by 2014.

Essential health benefits must include items and services within at least the following 10 categories:

    1.       Ambulatory patient services (outpatient services)
    2.       Emergency services
    3.       Hospitalization, including medically necessary surgeries and other inpatient procedures
    4.       Maternity and newborn care
    5.       Mental health and substance use disorder services, including behavioral health treatment
    6.       Prescription drug coverage
    7.       Rehabilitative and habilitative services and devices*
    8.       Laboratory tests and services
    9.       Preventive and wellness services and chronic disease management
  10.       Pediatric services, including oral and vision care

Health plans are allowed to impose cost sharing obligations on plan members for most essential benefits, but those that qualify under a category of preventive health services will be made available at no charge to plan members.

The ACA gives states authority to specify details surrounding the essential benefits. The states must each choose a benchmark plan that will serve as a more detailed definition of benefits within each of the ten Essential Health Benefit categories. California has selected the “Kaiser Foundation Health Plan, Inc. – Kaiser Foundation Health Plan Small Group HMO 30 ID 40513CA035″as its state benchmark plan.

* Rehabilitation covers services such as relearning to walk after a stroke. Habilitative services involve learning a new skill such as a speaking without a speech impediment.