Essential Health Benefits

All plans on the Marketplace must also offer a standard package of “Essential Health Benefits.” For complicated reasons the specific benefits can vary by state. Essential health benefits must include items and services within at least the following 10 categories:

  • ambulatory patient services (outpatient care without being admitted to a hospital)
  • emergency services
  • hospitalization (such as surgery)
  • maternity and newborn care
  • mental health and substance use disorder services, including behavioral health treatment (this includes counseling & pyschotherapy)
  • prescription drugs
  • rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including oral and vision care.

Benefits that fall under the categories of essential health benefits cannot have lifetime or annual dollar limits.

Q. Does this mean that there are no limits or restrictions on the plan I might get on the Marketplace?

A. No.  Health plans can still have limits.

  1. Although there can be no dollars limits for essential health benefits, plans can place limits on the number of visits or episodes for a particular service. For instance a plan might limit coverge for a skilled nursing facility to 60 days per year or the number of physical therapy visits to 30 per year.
  2. If a service falls outside of the 10 categories it does not have to be covered at all. Think acupuncture, massage therapy, etc.

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