The Affordable Care Act (ACA) requires all health insurance plans sold on the Health Insurance Marketplace and most individual and small-group plans to cover a set of Essential Health Benefits (EHBs). These benefits ensure that all Americans have access to comprehensive healthcare services, preventing insurers from offering limited plans that exclude critical medical services.
Understanding these 10 categories of essential health benefits can help individuals and families choose the right coverage and maximize their healthcare benefits.
1. Ambulatory Patient Services (Outpatient Care)
Ambulatory patient services refer to outpatient care, meaning medical services received without being admitted to a hospital. This includes:
- Doctor’s visits (primary care physicians and specialists)
- Outpatient surgery
- Preventive screenings
- Urgent care visits
- Telehealth services (virtual doctor visits, when included in a plan)
Since most medical care happens in outpatient settings, this benefit ensures policyholders have access to routine and preventive services without needing hospitalization.
2. Emergency Services
ACA-compliant plans must cover emergency care without requiring prior authorization and at in-network cost-sharing rates, even if you go to an out-of-network hospital. Emergency services include:
- Ambulance transportation (though air ambulance coverage may vary)
- Emergency room visits
- Treatment for severe conditions like heart attacks, strokes, or broken bones
This ensures that individuals receive necessary care in life-threatening situations without worrying about network restrictions or unexpected bills.
3. Hospitalization (Inpatient Care)
Hospitalization coverage includes the cost of:
- Inpatient hospital stays
- Surgery and anesthesia
- Medications administered in the hospital
- Post-surgical care
Without hospitalization coverage, the cost of a single hospital stay could be financially devastating. The ACA ensures these services are covered, though patients may still be responsible for deductibles, copays, or coinsurance.
4. Pregnancy, Maternity, and Newborn Care
The ACA made maternity and newborn care a required benefit, addressing a major gap in pre-ACA insurance plans. Coverage includes:
- Prenatal visits and screenings
- Labor and delivery (including hospital stays)
- Postnatal care (checkups for mothers and newborns)
Maternity care is covered even if a woman is already pregnant when she enrolls in a health plan—something that was often excluded before the ACA.
5. Mental Health and Substance Use Disorder Services
Mental health and addiction treatment services must be covered at the same level as physical health conditions (also known as parity). Coverage includes:
- Therapy and counseling (including cognitive behavioral therapy)
- Psychiatric services
- Substance use treatment (including rehab and detox programs)
- Prescription medications for mental health conditions
Since mental health services were often limited or excluded in pre-ACA plans, this requirement has expanded access to critical behavioral health treatments.
6. Prescription Drug Coverage
All ACA-compliant plans must cover at least one drug in every category and class listed in the U.S. Pharmacopeia. Covered medications typically include:
- Generic and brand-name prescription drugs
- Medications for chronic conditions (e.g., diabetes, asthma, hypertension)
- Mental health medications (e.g., antidepressants, antipsychotics)
- Cancer drugs and specialty medications
Each plan has a formulary (list of covered drugs) with cost-sharing tiers. Many states also require insurers to cover specific medications beyond federal guidelines.
7. Rehabilitative and Habilitative Services and Devices
These benefits cover therapies and medical equipment needed to recover from injuries, manage disabilities, or improve daily functioning. Coverage includes:
- Physical therapy (after surgeries, injuries, or strokes)
- Occupational therapy (for daily activities like dressing and eating)
- Speech therapy (for communication and swallowing disorders)
- Durable medical equipment (DME) (e.g., wheelchairs, prosthetics, braces)
Habilitative services (for conditions present from birth, such as cerebral palsy) and rehabilitative services (for injuries or illnesses like strokes) ensure that both children and adults receive the care they need.
8. Laboratory Services
ACA plans must cover both preventive and diagnostic lab tests, including:
- Blood tests (e.g., cholesterol, diabetes screening)
- Urine tests
- Genetic testing (when medically necessary)
- Tissue biopsies
- COVID-19 testing (under temporary pandemic provisions)
Diagnostic lab work is often required to detect and monitor medical conditions, making this an essential component of preventive and ongoing care.
9. Preventive and Wellness Services, and Chronic Disease Management
Preventive services help individuals avoid illness and detect conditions early. The ACA requires insurers to cover these services at no cost to the patient, meaning no copays, deductibles, or coinsurance. These include:
- Annual checkups and wellness visits
- Vaccinations (e.g., flu, COVID-19, HPV, tetanus)
- Screenings for cancer, diabetes, cholesterol, and blood pressure
- Contraceptive counseling and birth control
- Smoking cessation programs
The ACA also mandates chronic disease management services, such as:
- Diabetes management (including glucose monitors and insulin)
- Asthma treatment
- Heart disease care
These preventive services save lives and reduce long-term healthcare costs by catching diseases early.
10. Pediatric Services (Including Dental and Vision)
Unlike adult plans, ACA-compliant plans must cover pediatric dental and vision care for children under age 19. This includes:
- Routine eye exams
- Corrective lenses (glasses or contacts)
- Dental cleanings and exams
- Fillings, extractions, and some orthodontics
While adult dental and vision coverage is not required, separate plans are available for purchase.
Additional Considerations for Essential Health Benefits
Medicaid and Essential Health Benefits
Medicaid expansion plans (for states that adopted expansion under the ACA) must provide the same 10 essential health benefits as private ACA plans. However, states may set their own coverage rules for traditional Medicaid programs.
Grandfathered and Grandmothered Plans
Some older individual or employer-based plans that existed before March 23, 2010, may not cover all essential benefits if they are grandfathered or grandmothered (meaning they are exempt from some ACA rules). If you have one of these plans, consider switching to an ACA-compliant plan for full benefits.
Final Thoughts
The Essential Health Benefits (EHBs) required under the ACA ensure that all Americans have access to comprehensive medical care, including outpatient care, emergency services, maternity care, prescription drugs, and preventive screenings.
When selecting a health plan, it’s important to compare coverage details, networks, and costs to ensure you get the benefits that best fit your healthcare needs. By understanding these 10 essential categories, you can make an informed choice and maximize the value of your health insurance.
