Ten categories. Every ACA-compliant individual and small group plan must cover all of them. That is the essential health benefit requirement under the Affordable Care Act. The ten categories set the floor on what qualifies as real coverage. They do not set the cost-sharing, the formulary, or the network. Those vary by plan. Brokers who know the distinction spend less time explaining why a covered service still had a bill attached.
Key Takeaways
- All ACA-compliant individual and small group plans must cover ten essential health benefit categories. A plan that omits any of the ten is not a compliant plan.
- EHBs set the floor, not the ceiling. Plans must cover each category but set their own cost-sharing, formularies, and network restrictions within it.
- Preventive care services rated A or B by the US Preventive Services Task Force must be covered at no cost to the enrollee when received in-network.
- Prescription drugs are an EHB category, but EHBs do not require coverage of any specific drug. Formularies vary by plan. A drug covered on one plan may not be covered on another.
- Short-term health plans, grandfathered plans, and most employer self-insured plans are not required to cover EHBs. Clients switching from those plan types may be surprised by the difference.
The ten EHB categories
| EHB category | What it includes | What it does not guarantee |
|---|---|---|
| Ambulatory patient services | Outpatient care: doctor visits, urgent care, same-day procedures | Coverage of any specific out-of-network provider |
| Emergency services | Emergency room care. Federal law (No Surprises Act) limits balance billing for emergency care. | No cost-sharing. Plans can charge copays and coinsurance for ER visits |
| Hospitalization | Inpatient stays, surgery, and overnight care | Coverage of a specific hospital outside the plan network |
| Maternity and newborn care | Prenatal visits, labor and delivery, postpartum care, newborn coverage | Any specific birth location or provider |
| Mental health and substance use disorder services | Behavioral health, therapy, psychiatric care, substance use treatment. Must be covered at parity with medical benefits. | Any specific provider or unlimited sessions without prior authorization |
| Prescription drugs | At least one drug per USPSTF category in the plan formulary | Coverage of any specific drug. Formularies vary by plan |
| Rehabilitative and habilitative services | Physical therapy, occupational therapy, speech therapy, and devices that support these | Unlimited visits. Plans can set annual visit limits |
| Laboratory services | Diagnostic lab work ordered by a provider | Coverage of out-of-network labs |
| Preventive and wellness services | USPSTF A and B rated preventive services, immunizations, and certain screenings at no cost-sharing when in-network | No-cost preventive services from out-of-network providers |
| Pediatric services including oral and vision | Dental and vision care for children under 19 | Dental or vision coverage for adults. That requires a separate or rider plan |
EHBs set the floor, not the cost
The most common client confusion about EHBs is the assumption that coverage means no cost. It does not. Hospitalization is an EHB. A plan that requires the enrollee to meet a $4,000 deductible before hospitalization costs are covered is still covering hospitalization. The EHB requirement means the plan cannot exclude the category entirely. It says nothing about when the coverage kicks in.
The cost-sharing structure is what the metal tier controls. A Gold plan covers hospitalization at a higher actuarial value than a Bronze plan. Both cover hospitalization. Neither is in violation of the EHB requirement. For how metal tiers affect cost-sharing across EHB categories, read ACA metal tiers explained.
Prescription drugs: covered but not guaranteed
Prescription drugs are an EHB category, which means every ACA plan must have a drug formulary covering at least one drug in each required therapeutic category. What every ACA plan does not have is the same formulary. A specific maintenance medication covered on tier two with a $30 copay on one carrier's plan may be on tier four with a 40 percent coinsurance on another, or excluded entirely.
The formulary check is not optional for clients who take regular prescriptions. Run it before the plan recommendation, not after the enrollment. Every Marketplace plan's formulary is public. Most quoting tools, including GetInsured, surface formulary information during the plan selection flow. Quotit also includes formulary lookup for most carriers. The two minutes spent on a formulary check prevents the call where a client asks why their medication costs $400 on the plan the broker recommended.
Preventive care: the no-cost-sharing rule
Preventive services rated A or B by the US Preventive Services Task Force must be covered without cost-sharing when received in-network. This includes annual wellness visits, certain cancer screenings, blood pressure monitoring, and other evidence-rated preventive services. The no-cost-sharing requirement applies to in-network care. A client who goes out of network for a preventive service may still face a bill.
Some preventive services have been subject to legal challenges regarding the no-cost-sharing requirement. The landscape has shifted in court decisions since the ACA's passage. Brokers should avoid guaranteeing specific preventive services are free on every plan and instead direct clients to verify with the carrier for the specific plan year.
Mental health parity: what coverage means in practice
The ACA requires that mental health and substance use disorder benefits be covered at parity with medical and surgical benefits. A plan cannot impose visit limits on mental health therapy if it does not impose comparable limits on physical therapy. Prior authorization requirements for behavioral health must not be more restrictive than those for comparable medical services.
In practice, prior authorization for mental health services is common and the parity enforcement is not automatic. Clients with significant behavioral health needs should verify specific plan prior authorization rules before enrolling. The EHB category means the plan must cover the service. It does not mean the plan cannot require prior authorization for it.
Plans that do not have to cover EHBs
Not every health plan is subject to the EHB requirement. Three categories are commonly misunderstood.
Short-term health plans are not ACA-compliant and can exclude any EHB category. Most do exclude maternity, mental health, and prescription drugs. Clients who moved from a short-term plan to Marketplace coverage often do not realize how much broader their new coverage is until they use it.
Grandfathered plans that have not been significantly changed since March 2010 may be exempt from some or all EHB requirements. These are increasingly rare in the individual market.
Large employer self-insured plansare governed by ERISA, not the ACA's EHB rules. Clients coming off large employer coverage may be moving to a plan that covers different categories in different ways. The network type conversation and the formulary check are especially important for those transitions. For how to assess a client's network options after a coverage transition, read ACA network types: HMO, PPO, EPO, and POS explained.
Clients comparing short term products need the contrast with compliant coverage. See short term health plans vs ACA.
FAQ
Common questions about essential health benefits and what they do and do not cover.
Do all ACA plans cover the same drugs?
No. Prescription drugs are an EHB category, which means every plan must have a formulary that covers drugs across required therapeutic categories. But plans choose which specific drugs to include. A drug covered at a low tier copay on one plan may be excluded or on a high-cost tier on another. Brokers whose clients take specific maintenance medications should run a formulary check before recommending a plan.
Are adult dental and vision covered under EHBs?
No. Pediatric dental and vision (for children under 19) are EHBs. Adult dental and vision are not. Adult coverage requires a separate dental or vision plan, or a plan that includes those benefits as a rider. Some carriers bundle adult dental or vision into their Marketplace plans, but this is not required.
Do short-term health plans cover EHBs?
No. Short-term plans are not ACA-compliant and are not required to cover any of the ten EHB categories. They typically exclude maternity, mental health, and prescription drug coverage entirely. Clients who purchase short-term plans expecting ACA-equivalent coverage are not protected by the EHB requirement. Brokers who explain this distinction prevent complaints when a client's claim is denied.
Is mental health coverage actually enforced at parity with medical coverage?
Federal mental health parity law requires that behavioral health benefits not be more restrictive than comparable medical benefits. In practice, enforcement varies, and prior authorization requirements for mental health services are more common than for equivalent medical services. Clients with significant mental health needs should verify specific plan prior authorization rules, not rely solely on the EHB category coverage guarantee.
Are EHBs covered the same way at every cost-sharing level?
No. EHBs set the coverage floor. A plan must cover the service, but do not dictate cost-sharing. A hospitalization under an EHB requirement may still be subject to a deductible, copay, or coinsurance. The metal tier determines the actuarial value, which affects how much the plan pays on average. EHBs and metal tiers are separate concepts. Every ACA plan covers hospitalization. Not every plan covers it at the same cost to the enrollee.
