Requirements Generally Apply to Plans Offered in Individual and Small Group Markets

Under the Affordable Care Act (ACA) and its corresponding regulations, non-grandfathered health plans offered in the individual and small group health insurance markets are generally required to cover a core package of items and services known as “essential health benefits.” (This requirement does not apply to self-insured plans or plans offered in the large group market.)

Essential health benefits must include items and services in the following ten benefit categories:

1.    Ambulatory patient services;
2.    Emergency services;
3.    Hospitalization;
4.    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.

The essential health benefits must be equal in scope to benefits offered by a “typical employer health plan.” A final rule issued by the U.S. Department of Health and Human Services defines essential health benefits based on state-specific essential health benefits benchmark plans, and provides that all plans subject to the essential health benefits requirements offer benefits substantially equal to the benefits offered by the benchmark plan. For more information on EHB-benchmark plans for each of the 50 states and D.C., click here.

Note: If allowed by a particular state and insurance company, a small business may be able to renew its current group plan through December 31, 2018, even though the coverage does not comply with the requirement to cover essential health benefits.

Click here for more information on essential health benefits.

Visit our ACA by Year & Company Size section for an overview of other ACA requirements.