Essential Health Benefits

The ACA's minimum coverage list

The Affordable Care Act requires every ACA-compliant individual and small group plan to cover ten categories of care, called essential health benefits. They are:

1. Outpatient care, such as doctor visits and outpatient procedures.
2. Emergency services.
3. Hospitalization, including surgery and overnight stays.
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, like physical therapy and occupational therapy.
8. Laboratory services.
9. Preventive and wellness services and chronic disease management.
10. Pediatric services, including dental and vision care for children.

What this means in practice

Plans can differ in networks, cost sharing and formularies, but they cannot drop an entire category. They also cannot put annual or lifetime dollar limits on these benefits. Each state sets a benchmark plan that defines the details, such as how many therapy visits are covered.

Example

Mia and her husband run a small marketing agency and are planning to start a family. They are comparing an ACA-compliant plan with a lower-priced private plan.

• The ACA plan covers prenatal visits, delivery, newborn care and postpartum mental health support under the essential health benefits.
• The private plan excludes maternity care, or covers it only after a long waiting period.

For Mia and her husband, the ACA plan's maternity coverage is non-negotiable, and the comparison becomes simple.

Plans that may not include all ten

Some types of coverage are not required to include essential health benefits:

• Short-term health plans, which often exclude maternity, mental health and prescriptions.
• Fixed indemnity and limited benefit plans, which pay set amounts per service.
• Health care sharing ministries, which are not insurance at all.
• Some underwritten private plans that are not ACA-compliant.

These options can make sense for specific situations, but you need to know what is missing.

Marketplace vs private plans

All Marketplace plans include essential health benefits, and so do ACA-compliant plans sold off the exchange. Private plans outside the ACA rules may include some, most or few of these categories. A plan that covers doctor visits and hospital stays well may still skip maternity or limit mental health care. Read the exclusions section first.

Questions to ask

• Is the plan ACA-compliant?
• If not, which of the ten categories are excluded or limited?
• Are there annual or per-condition dollar caps?

Our guides comparing short-term vs ACA health insurance and health sharing vs insurance explain these trade-offs. To see a plan's benefit list side by side with alternatives, start a quote.