Essential Health Benefits

What are essential health benefits?​​

Essential health benefits (EHB) is a related concept to minimum essential coverage. The requirement to cover EHB applies to health insurers offering non-grandfathered health insurance coverage in the individual and small group markets only. Self-funded group health plans, large group health insurance coverage, and grandfathered plans are not required to provide EHB.

However, such plans and coverage generally are prohibited from imposing annual or lifetime dollar limits on any EHB that they do offer. Notably, however, the proposed EHB regulations provide an out-of-pocket limit. This out-of-pocket limit applies to grandfathered plans, as well as self-funded plans and large group insured coverage (this limit is yet to be determined).

EHB regulations are effective on the first day of the first plan year following 1-1-2014. If a group’s plan year is the same as its renewal date, then the change will go into effect upon renewal. If an employer’s plan year is something different than its renewal date, then the changes will be effective upon the plan year.

Do the Essential Health Benefit requirements apply to large groups in 2014? For example if I’m a large employer, do I have to implement EHB?​​


How will the cost-share for essential health benefits (EHB) affect non-grandfathered employer groups, and does it apply to grandfathered groups?  

The out-of-pocket maximum on EHB only affects non-grandfathered self-funded groups. Grandfathered plans would be protected.

ACA’s essential health benefits include pediatric services for dental and vision. Is this benefit going to be covered under the medical policy or does it apply to specific dental and visions policies on a stand-alone basis? 

Per the regulations, pediatric vision services must be included in the medical policy. However, pediatric dental services may be offered in a medical contract or may be offered as a stand-alone policy on the Marketplace if another pediatric dental plan is available. Stand-alone and embedded pediatric dental services are also available off the Marketplace.