What are the essential health benefits or EHB?
Essential Health Benefits/EHB of the ACA
There are 10 “essential health benefits” that all health plans must provide to be considered compliant with the Affordable Care Act. Before the passing of the ACA only 2% of plans provided all 10 benefits. All EHB plans must cover the state’s benchmark service’s as well as not have a lifetime maximum or annual limit. Below is a list of the 10 EHB or essential health benefits as defined by the Affordable Care Act or Obamacare.
1. Outpatient Services
Any health care you can get without staying in a hospital is considered an outpatient service. That includes Dr. visits, diagnostic tests, treatments, or rehab visits. Most wellness and prevention services like counseling and physicals are outpatient services.
2. Emergency services
These benefits are when you use the emergency room in your local hospital. Whether it be from a sickness that can’t wait until the Dr. is open or a broken arm this must be covered. Most plans already include emergency services. Some plans have a separate deductible for emergency services and some charge extra if you go out of network.
3. Hospitalization
Anytime you are admitted to the hospital it is considered a hospitalization service. A day in the hospital can easily run you $20,000 and not all plans cover enough of in hospital stays. If you have a high deductible health plan (HDHP) or a plan with a high max out of pocket, you may have to pay tens of thousands before your insurance will be applied. Make sure you understand your plans limit and benefits when it comes to in hospital coverage.
4. Maternity and newborn care
This is a needed benefit for many young families. It goes beyond just the actual delivery of the child and doctors’ visits. It includes things like genetic counseling, reviews of pre-existing conditions in regard to childbearing, social support counseling, guidance on nutrition, prenatal care, parenting education, fetal evaluation, ultrasounds, immunizations and more.
5. Mental and behavioral health
These benefits include mental health as well as treatment for alcohol and drug abuse. Many insurance companies try to avoid paying for these treatments as they are long term commitments. But now due to passing of the essential health benefits in the ACA all plans must have them to be considered ACA compliant.
6. Prescription drugs
ALL EHB plans must cover at least one drug in every U.S. Pharmacopeia category and class. Meaning they must cover at least 1 of each drug type. Your out of pocket drug expenses will count towards your deductible as well.
7. Devices, equipment and medical durable supplies for people with injuries, disabilities, or chronic conditions
This part of the EHB benefits is what states they must cover things like casts for a broken leg or devices to help someone with Multiple sclerosis with their back. Without these added benefits plans may not cover wheelchairs or crutches when needed.
8. Laboratory services
Laboratory tests include certain blood tests, urinalysis, tests on tissue specimens, biopsies, chemotherapy, colonoscopies, CT scans, mammograms, radiation treatments, ultrasounds, x-rays and even minor surgical procedures.
9. Preventive and wellness services and chronic disease management
Most health plans must cover a set of preventive services, like shots and screening tests, at no cost to you. The ACA or Obamacare requires all 50 procedures recommended by the U.S. Preventive Services Task Force be covered with no copay.
Note: These services are free only when delivered by a doctor or other provider in your plan’s network.
10. Pediatric services, including oral and vision care
Children must receive all the above essential health benefits as well as dental and vision coverage.
Do I need to pay for ALL of the essential health benefits?
In short, yes and no. If you decide to go with an ACA compliant plan then yes, you would have to pay for all of them. If you decide to go with a plan outside of the marketplace then you do not. It really depends on your personal situation which option would be better. Let’s say you are 20 years old and just getting insurance to be safe, but next year you get pregnant. You will be happy you had maternity coverage. But let’s say you were a man or a woman with a hysterectomy. You may find a plan that doesn’t cover maternity and could save you some money monthly.
While there is obviously great benefit in having these benefits guaranteed in your plan, there are times they aren’t needed, and cost savings can be applied. We recommend always speaking to a licensed agent to weigh out your options before you make any major changes in your health coverage.
How Trumpcare/AHCA (American Health Care Act) impacts your EHB/Essential health benefits
As of the time of this article being published, for a plan to be considered ACA compliant, they will still need to cover these needs as described. Now with that being said, the passing of the AHCA or Trumpcare has expanded options to group association plans which will not have to follow these same guidelines. The idea is limiting certain services that aren’t needed for all, such as mental health/substance abuse treatment or maternity coverage.
These plans can offer great savings and some do cover all of these services, just ensure you are dealing with a trustworthy licensed insurance agent who can explain all of the benefits and down sides to each plan. The limits in coverage may or may not impact you.
