Essential Health Benefits Coverage and Cost-Sharing Rules

Starting in 2014, non-grandfathered small group health plans must cover basic health services, called essential health benefits (EHBs), such as:

  • Ambulatory patient services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Rehabilitative and habilitative services and devices
  • Prescription drugs
  • Emergency services
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

Grandfathered group health plans and large group health plans don't have to cover EHBs. However, if they choose to, they can't set annual or lifetime dollar limits.

Understanding ACA
If you get preventive care services from a doctor who's in your insurance plan's network, you may not have to pay out-of-pocket costs for your visit.

Cost-Sharing Rules

Non-grandfathered group health plans covering EHBs must also follow cost-sharing rules. Both small group and large group plans must limit annual out-of-pocket member expenses for in-network EHBs.