Essential Health Benefit Package Requirements

Explanation

As of 2014, the Affordable Care Act (ACA) requires that non-grandfathered health insurance coverage offered in the individual and small group markets, both on and off of the health insurance exchanges, offer a standard package of coverage known as “essential health benefits.” ACA requires the following categories of essential health benefits to be included: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services (including oral and vision care). In addition, the benefit plan for non-grandfathered individual and small group health insurance policies must adhere to other benefit requirements, including cost-sharing requirements and actuarial value requirements.

Questions and answers

  • Do plans have to include the essential health benefit package? 
  • What is the essential health benefit package? 
  • Are large group plans subject to any of these requirements? 

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