Essential Health Benefits Requirements
The Affordable Care Act requires individual and small group health plans to cover ten categories of Essential Health Benefits (EHBs) — a minimum coverage floor that defines what counts as real health insurance. The categories include ambulatory services, emergency care, hospitalization, maternity and newborn care, mental health and substance use disorder treatment, prescription drugs, rehabilitative services, laboratory services, preventive care, and pediatric services including dental and vision for children. Before the ACA, insurers routinely sold "skinny" plans that excluded maternity coverage (treating it as a rider), mental health services, or substance use treatment — leaving people with coverage gaps they discovered only when they needed care. The EHB requirement ended those exclusions for individual and small group plans. Large employer plans (50+ employees) and self-insured plans are not required to cover EHBs — though most offer comparable coverage. The definition of each benefit category is anchored to a state-specific "benchmark plan" (typically the largest small group plan in the state), meaning the exact scope of covered services varies by state. Mental health parity requirements (separate federal law) require that EHB mental health and substance use coverage be no more restrictive than coverage for medical/surgical conditions.
Current Law (2026)
The ACA requires individual and small group health plans to cover ten categories of Essential Health Benefits (EHBs).
| Category | Examples |
|---|---|
| 1. Ambulatory patient services | Doctor visits, outpatient surgery |
| 2. Emergency services | ER visits (in-network cost-sharing regardless of provider) |
| 3. Hospitalization | Inpatient care |
| 4. Maternity and newborn care | Prenatal, delivery, postpartum |
| 5. Mental health and substance use | Counseling, inpatient treatment, medication-assisted treatment |
| 6. Prescription drugs | At least one drug per formulary class |
| 7. Rehabilitative and habilitative services | Physical therapy, occupational therapy, devices |
| 8. Laboratory services | Blood work, imaging |
| 9. Preventive and wellness | Screenings, immunizations, wellness visits (no cost-sharing) |
| 10. Pediatric services | Dental and vision for children |
Legal Authority
- 42 U.S.C. § 300gg-3 — Prohibition of preexisting condition exclusions or other discrimination based on health status
- 42 U.S.C. § 300gg-4 — Prohibition of discrimination based on health status (wellness programs, nondiscrimination)
- 42 U.S.C. § 300gg-5 — Non-discrimination in health care (providers in good standing)
- 42 U.S.C. § 18022 — Essential health benefits package (ten required benefit categories, actuarial value tiers)
- ACA Section 1302 — Essential health benefits requirements
How It Works
The EHB framework under 42 U.S.C. § 18022 does not specify a uniform national benefit package — it delegates to each state the selection of a benchmark plan that defines the scope of required coverage in that state. States typically designate the largest small group insurer's plan as the benchmark; individual and small group plans must then cover at least the same services across all ten categories. The exact scope of EHB-covered services (which specific drugs, which rehabilitative devices, which mental health treatments) therefore varies by state even though the ten-category framework is nationally uniform. Plans cannot impose annual or lifetime dollar limits on EHBs.
EHB requirements apply to individual and small group market plans — including ACA marketplace plans. Large group plans (employers with 50+ employees) and self-insured plans — the structure used by most large employers — are not required to cover all ten EHB categories, though most voluntarily provide comparable coverage. Separately, the ACA requires $0 cost-sharing for preventive services assigned an A or B rating by the USPSTF — including colonoscopies, mammograms, immunizations, contraception, and annual wellness visits. This zero-cost-sharing requirement has faced legal challenges; its current status depends on ongoing litigation.
The Mental Health Parity and Addiction Equity Act, combined with the EHB requirement, prohibits insurers from imposing more restrictive treatment limits, prior authorization requirements, or cost-sharing on mental health and substance use disorder benefits than on comparable medical/surgical benefits. EHBs require that the coverage exist; parity rules govern how it must be designed. See SAMHSA for the federal agencies and grants funding SUD treatment beyond insurance. Short-term limited-duration plans are specifically exempt from EHB requirements — they can legally exclude maternity coverage, mental health services, and pre-existing conditions, which is why they're sometimes called "junk insurance."
How It Affects You
If you buy coverage through the ACA marketplace: EHBs define what must be covered — your comparison shopping should focus on how much you pay for covered services, not whether those services are covered. Before enrolling, every plan is required to post a Summary of Benefits and Coverage (SBC): a standardized 4-page document showing deductibles, copays, coinsurance, and out-of-pocket maximums. Find it at healthcare.gov by clicking a plan name in the plan comparison view, or by calling the plan directly — the number is on your ID card. The SBC shows "Important Questions" including your deductible and the specific costs for common services (primary care, specialist, ER, hospital admission). Use the SBC, not the insurer's marketing brochure, to compare plans. If your claim is denied, you have 180 days to file an internal appeal through your insurer; if the internal appeal fails, you can request an external review by an independent organization under 45 CFR Part 147.
If you're considering a short-term health plan: Short-term plans are explicitly exempt from EHB requirements under 42 U.S.C. § 18022 — they can legally exclude maternity care, mental health treatment, prescription drugs, preventive care, and pre-existing conditions. The Trump administration has restored the ability to sell short-term plans for up to 36 months (Biden-era rules limited them to 4 months). These plans are marketed by price, and the premium savings can be real. The coverage gaps are also real. Before enrolling: read the exclusion section of the plan document (not the summary brochure), specifically looking for pre-existing condition exclusions, mental health exclusions, and prescription drug coverage. If you have any ongoing prescriptions, scheduled procedures, or history of mental health treatment, a short-term plan may refuse to pay for exactly those services.
If you want to use free preventive care: ACA-compliant plans must cover USPSTF A/B-rated services at $0 cost-sharing, including: annual wellness visits, blood pressure screening, cholesterol screening, diabetes screening (fasting glucose or A1c), colonoscopy at 45+, mammograms, cervical cancer screening, PrEP (HIV prevention medication), statins for cardiovascular prevention at 40-75 with risk factors, and most childhood immunizations. You pay nothing when the service is billed as preventive and the provider is in-network. Important caveat: The Braidwood v. Becerra litigation (currently before the Supreme Court as of 2026) challenges whether USPSTF recommendations made after the ACA was enacted can be enforced as mandates. PrEP, certain cancer screenings, and other newer recommendations may face cost-sharing requirements pending the case's resolution. Call your insurer to confirm $0 cost-sharing before assuming a newly recommended service is free.
If your mental health claim was denied or restricted: File a parity violation complaint. The EHB requirement + Mental Health Parity and Addiction Equity Act (MHPAEA) means your plan cannot impose prior authorization requirements, visit limits, or higher cost-sharing for mental health care that it doesn't also impose for comparable medical/surgical care. If your plan requires prior authorization for mental health sessions but not for physical therapy, that's a potential parity violation. File complaints with: your state insurance commissioner (find yours at naic.org/state_web_map.htm), and for employer-sponsored plans, DOL's Employee Benefits Security Administration (dol.gov/agencies/ebsa or 1-866-444-3272). 2024 MHPAEA regulations require plans to provide their parity analysis on request — ask your insurer in writing for their Non-Quantitative Treatment Limitation (NQTL) comparative analysis if your claim is repeatedly denied.
Implementing Regulations
- 45 CFR Part 156 — Health insurance issuer standards (§§ 156.100, 156.105 — state selection of EHB benchmark plan, determination of EHB for multi-state plans)
- 45 CFR Part 147 — Health insurance reform requirements (§ 147.150 — coverage of essential health benefits)
- 42 CFR Part 440 — Medicaid services (§ 440.347 — essential health benefits for Medicaid expansion population)
Pending Legislation
- HR 6421 — Expand eligibility for catastrophic health plans under the ACA. Status: Introduced.
- EHB scope changes: Proposals to add hearing, adult dental/vision, or other categories.
- Short-term plan regulation: Proposals to restrict or eliminate short-term plans that bypass EHB requirements.
Recent Developments
- Braidwood v. Becerra — preventive care mandate challenged: The Fifth Circuit ruled in 2023 that the ACA's requirement for health insurers to cover certain preventive services at no cost — specifically those recommended by the U.S. Preventive Services Task Force (USPSTF) after the ACA was enacted — may be unconstitutional because USPSTF members were not Senate-confirmed federal officers. The case has been working through courts since, with significant uncertainty about whether free preventive care coverage (colonoscopies, mammograms, HIV prevention drugs like PrEP, statin prescriptions) can be required without cost-sharing. If the challenge prevails, plans could begin charging copays for services previously covered at $0.
- Short-term health plan expansion: The Trump administration has moved to expand the availability of short-term limited duration insurance (STLDI) plans, which are exempt from EHB requirements. Biden-era regulations had restricted short-term plans to 4-month maximum duration; the current administration is reverting to the prior 36-month maximum. If you're shopping for lower-premium coverage, be aware that short-term plans can legally exclude maternity care, mental health services, prescription drugs, and pre-existing conditions — all of which are required EHBs on ACA-compliant plans.
- Mental health parity enforcement: The Mental Health Parity and Addiction Equity Act (MHPAEA) was strengthened by regulations finalized in 2024, requiring plans to conduct and disclose their parity analysis showing that mental health benefits are not more restrictive than medical/surgical benefits. These requirements survived the CFPB rollback because they're administered by DOL and HHS, not CFPB. If your insurer has been denying mental health claims at higher rates than medical claims, the parity rules give you an administrative appeal basis.
- Long-term care exclusion: Long-term care is notably absent from EHBs, leaving tax-advantaged insurance as one of the few planning tools for that risk. See Long-Term Care Insurance Tax Treatment for the deductibility rules.
- GLP-1 drugs and formulary coverage: Insurers' obligations to cover GLP-1 medications (Ozempic, Wegovy, Mounjaro) under the prescription drug EHB category are actively contested. The FDA approved Wegovy specifically for weight management (not just diabetes), but plans have generally argued they're not required to cover drugs used primarily for weight loss. CMS has proposed extending Medicare coverage for anti-obesity medications; whether this changes commercial insurer obligations is still evolving.