What are essential health benefits?

Under the Affordable Care Act (ACA) all health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, must offer a comprehensive package of items and services, known as the “essential health benefits.”

The ACA stipulates that essential health benefits include items and services within at least the following 10 categories:

  1. Ambulatory patient services;
  2. Emergency services;
  3. Hospitalization;
  4. Pregnancy, maternity and newborn care;
  5. Mental health and substance use disorder services, including behavioral health treatment;
  6. Prescription drugs;
  7. Rehabilitative and habilitative services and devices;
  8. Laboratory services;
  9. Preventive and wellness services and chronic disease management; and
  10. Pediatric services, including oral and vision care.

It is important to note, however, that these items and services might have cost sharing associated with them (like deductibles, co-pays, and co-insurance) depending on the details of your plan. That means that while your plan will pay part of the cost of these items and services, they are likely not going to be free to you. The exception is for preventive care. All insurance plans must provide preventive care at no cost to you – even if you haven’t yet satisfied your deductible. This means you can get recommended immunizations and screenings for free if you see an in-network provider.