The Essential Health Benefits (EHBs) are ten broad categories of health care services that Marketplace health plans and certain other private market plans must cover to help ensure people have access to basic health care services (see list below). The EHB requirement has closed health care coverage gaps that for years had left individuals underinsured. Prior to the Affordable Care Act requiring coverage of EHBs, federal law did not require minimum coverage standards. As a result, consumers often did not have health coverage for services now covered as EHBs, such as maternity care, mental health, or substance use disorder services.
Preventive health services, including family planning services, are also among the EHBs. Preventive care is critical for an effective health care system, both in terms of health status and cost control. Without preventive services, conditions may be more advanced when detected, and lead to unnecessary hospitalizations, costly management of acute and chronic conditions, and other cost-drivers. While the EHBs are a federal requirement, states have significant flexibility in determining the items and services that health plans in their states must cover as EHBs.
The Notice of Benefit and Payment Parameters for 2019 final rule, released in April 2018, made significant changes to the EHB standard. States can now make changes to their EHBs annually. NHeLP monitors EHB state activity, and provides technical assistance to advocates and stakeholders.
Essential Health Benefits Categories
- Ambulatory patient services
- Emergency services
- 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 (including chronic disease management and family planning)
- Pediatric services, including oral and vision care
- Issue Briefs
- Blog Posts
- Webinar Links
- Press Releases
- CMS Resources
Essential Health Benefits Benchmarking Process (April 2020)
New EHB standard:
Overview of Changes to the EHB standard (April 2018)
EHB Rx Drug Series:
Issue #1 – Formulary Transparency
Issue #2 – Exceptions Process
Archive (Documents before the most recent changes to the EHB standard)
NHeLP Comments on Proposed Changes to EHBs (Nov 2017)
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We are currently tracking state bills that have been introduced during the current legislative session. We are doing our best to update this chart on a regular basis. However, if you have any corrections to the chart or any questions for us, please contact NHeLP Policy Analyst Alexis Robles at [email protected].