essential health benefits

What are the 10 essential benefits mandated by the ACA?

The ACA defines ten essential health benefits:

• Hospitalization
• Ambulatory services (visits to doctors and other healthcare professionals and outpatient hospital care)
• Emergency services
• Maternity and newborn care
• Mental health and substance abuse treatment
• Prescription drugs (including brand-name drugs and specialty drugs)
• Lab work
• Preventive care services recommended by the U.S. Preventive Services Task Force (USPSTF), the Health Resources and Services Administration (HRSA), and the CDC’s Advisory Committee on Immunization Practices (ACIP).  This amounts to a fairly extensive list of services, including things like contraception, blood pressure screening, breast cancer screening, colorectal cancer screening, obesity screening and counseling, tobacco use counseling and interventions, and breastfeeding counseling. It also includes recommended vaccines, including COVID vaccines. But not all preventive services are covered, so it’s important to understand how this works before scheduling a checkup. And some services — such as mammography and colonoscopy — are fully paid for by insurance if they’re done as preventive care in an asymptomatic person, but will require normal cost-sharing if they’re done for diagnostic reasons, such as investigating a lump that you or your doctor found. 
• Pediatric dental and vision care (there is some flexibility on the inclusion of pediatric dental if the plan is purchased within the exchange)
• Rehabilitative and habilitative services 

Has a lawsuit changed the rules for preventive care coverage?

For the time being, no. But a federal judge has ruled against requiring USPSTF recommendations to be covered by health insurers. That case is still up in the air as of early 2023, and no final order has been issued. That’s expected in 2023, and the ruling is also expected to be appealed.

Is contraception an essential health benefit?

Yes, female contraception is part of the ACA’s preventive care essential health benefit. To be clear, contraception coverage is not specifically spelled out in the ACA as one of the essential health benefits. Instead, the law directed the Health Resources and Services Administration (HRSA) to define woman-specific services that must be covered under the preventive care EHB category. So HRSA developed those guidelines, and they include coverage for the full range of female contraceptives approved by the FDA.

However, the rules for employer exemptions from the contraceptive coverage mandate have changed over the years.

The Obama administration created an exemption for religious organizations, and an accommodation process by which women with coverage under exempt organizations could still access zero-cost contraception. The Trump administration expanded the exemption to also include organizations with moral objections, and made the accommodation optional for plan issuers with exemptions.

But the Biden administration has proposed a rule change in 2023 that would eliminate the moral objection exemption, and that would ensure a way for women to obtain zero-cost contraception, even if they’re enrolled in a plan that has a religious exemption from the contraception mandate.

Are ACA essential benefits the same in every state?

The ACA outlined the essential health benefits as broad categories of care, and it’s up to each state to define exactly what has to be covered under each essential health benefit category. States do this by designating a benchmark health plan, (See definition 2 here.)

So although the ACA’s essential health benefit categories are the same in every state, the specifics of exactly what has to be covered by individual and small group health plans will vary from one state to another.

We can look at physical therapy – which is part of the habilitative/rehabilitative EHB – for a good example of how this works in a couple of states:

• New York has designated an Oxford EPO small group plan as its benchmark. That plan includes coverage for up to 60 physical therapy visits per year, but notes that “Speech & physical therapy are only covered following a hospital stay or surgery.” So insurers offering individual and small group coverage in New York are not required to cover physical therapy if the patient has not had a hospital stay. They can choose to go above and beyond that coverage level, but they don’t have to.
• Now let’s consider another state. Colorado’s benchmark plan limits physical therapy to just 20 visits per year, but physical therapy is “covered if, in the judgment of a Plan Physician, significant improvement is achievable within a two-month period.” So insurers in Colorado must cover up to 20 physical therapy visits per year, and cannot limit coverage only to those who had a prior hospital stay.

This is just one example of how “covered” doesn’t mean covered in the same way from one state to another. It all depends on the benchmark plan in your state, as well as state-specific benefits mandates that a state has implemented via the legislative process (for example, requiring all state-regulated health plans to cover male contraception, which goes beyond what the federal government requires in terms of contraceptive coverage).

How many people have coverage for the ACA’s essential health benefits?

Millions of Americans have coverage for the ACA’s essential health benefits, including:

• Roughly 16.3 million people enrolled in on-exchange individual market coverage during the open enrollment period for 2023 plans, and that number increases to 17.5 million when you include the Basic Health Program enrollees in New York and Minnesota.
• In addition, there were an estimated 2.1 million people with ACA-compliant off-exchange coverage in 2019 (off-exchange enrollment isn’t tracked the way on-exchange enrollment is, although we know that it has declined fairly significantly since the plans first debuted in 2014; California’s marketplace estimated that nationwide off-exchange enrollment stood at about 1.5 million people in 2021).
• All non-grandfathered, non-grandmothered small group health insurance plans also include coverage for essential health benefits.
• Medicaid also covers the essential health benefits, and total enrollment in Medicaid/CHIP has grown by more than 34 million people since 2013, due in large part to Medicaid expansion under the ACA and the ongoing COVID pandemic (enrollment will start to decrease in 2023, due to the end of the pandemic-related continuous coverage requirement for Medicaid).

Grandmothered and grandfathered plans are not required to cover the ACA’s essential health benefits, although grandmothered plans are required to cover recommended preventive care with no cost-sharing. Large group plans are also not required to cover essential health benefits (but if they do, they cannot impose dollar limits on the benefit), although they are required to cover recommended preventive care without any cost-sharing, unless they’re grandfathered.