Essential Health Benefits: What Every ACA Plan Must Cover

The 10 Essential Health Benefits

The Affordable Care Act requires all ACA-compliant health insurance plans (marketplace plans, most employer plans, and individual plans sold since 2014) to cover the following 10 categories of care, called Essential Health Benefits (EHBs):

1. Ambulatory patient services (outpatient care — office visits, clinics)
2. Emergency services (emergency room visits)
3. Hospitalization (inpatient hospital stays and surgery)
4. Maternity and newborn care (prenatal, labor, delivery, postnatal)
5. Mental health and substance use disorder services (therapy, counseling, inpatient psychiatric)
6. Prescription drugs (at least one drug per covered category in the formulary)
7. Rehabilitative and habilitative services and devices (physical therapy, occupational therapy, speech therapy)
8. Laboratory services (blood work, diagnostic testing)
9. Preventive and wellness services (annual physicals, immunizations, cancer screenings)
10. Pediatric services (pediatric dental and vision for children under 19)

What EHBs Do NOT Include

Essential health benefits are a floor, not a ceiling. Plans can (and often do) cover additional services beyond EHBs. But there are notable gaps in what EHBs require:

• Adult dental care is NOT an EHB (only pediatric dental is required)
• Adult vision care is NOT an EHB (only pediatric vision is required)
• Adult hearing aids are NOT an EHB
• Infertility treatment is NOT an EHB (though some states mandate it)
• Weight loss surgery is NOT an EHB
• Long-term care is NOT an EHB

Preventive Care: Covered at $0

All ACA plans must cover a specific list of preventive services at no cost to you — meaning $0 copay, $0 deductible, $0 coinsurance — when provided by an in-network provider. These include annual physicals, cancer screenings (mammograms, colonoscopies), immunizations, blood pressure checks, diabetes screening, and more. The specific list is determined by the USPSTF, ACIP, and HRSA advisory bodies.