In the

United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...

, essential health benefits (EHBs) are a set of ten benefits, defined under the

Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and informally as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...

(ACA) of 2010, that must be covered by individually-purchased health insurance and plans in small-group markets both inside and outside of health insurance marketplaces. Large-group health plans, self-insured ERISA plans, and ERISA-governed multi-employer welfare arrangements that are not subject to state insurance law are exempted from the requirement.Sara Rosenbaum, Joel Teitelbaum & Katherine Hayes
The Essential Health Benefits Provisions of the Affordable Care Act: Implications for People with Disabilities

Commonwealth Fund The Commonwealth Fund is a private American foundation whose stated purpose is to "promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, inc ...

(March 2011).

Definition

The Affordable Care Act (ACA) set forth the following ten categories of essential health benefits,Alexandra Ernst
10 Essential Health Benefits Insurance Plans Must Cover Starting in 2014
, FamiliesUSA (March 28, 2013). at Section 1302(b)(1) of the ACA, codified at 42 U.S.C. § 18022(b): Health insurance plans must cover these benefits i.e. they must cap people's out-of-pocket spending and must not limit annual and lifetime coverage.

Interpretation

The essential health benefits are a minimum federal standard and "states may require that qualified health plans sold in state health insurance exchanges also cover state-mandated benefits." The act gives "considerable discretion" to the Secretary of Health and Human Services to determine, through regulation, what specific services within these classes are essential. However, the Act provides certain parameters for the secretary to consider. The secretary (1) must "ensure that such essential health benefits reflect an appropriate balance among the categories ... so that benefits are not unduly weighted toward any category"; (2) may "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life"; (3) must take into account "the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups"; and (4) must ensure that essential benefits "not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or the individuals' present or predicted disability, degree of medical dependency, or quality of life." According to a

report in 2011:

Law history

Coverage of essential health benefits was first required by the 2010

Patient Protection and Affordable Care Act A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health ...

(PPACA or ACA), which was a major piece of health care reform legislation.Frank Lalli
The Health Care Law's 10 Essential Benefits: The Affordable Care Act ensures you'll have access to these medical and wellness services
'' AARP The Magazine'' (August/September 2013). The EHB provisions of the ACA was an amendment to the

Public Health Service Act The Public Health Service Act is a Law of the United States, United States federal law enacted in 1944. The full act is codified in Title 42 of the United States Code (The Public Health and Welfare), Chapter 6A (United States Public Health Servi ...

. Lavarreda, director of health insurance studies for the

UCLA The University of California, Los Angeles (UCLA) is a public land-grant research university in Los Angeles, California, United States. Its academic roots were established in 1881 as a normal school then known as the southern branch of the C ...

Center for Health Policy Research, explained that before the ACA's passage, U.S. health insurance sector experienced "a

race to the bottom Race to the bottom is a Socioeconomics, socio-economic concept describing a scenario in which individuals or companies compete in a manner that incrementally reduces the utility of a product or service in response to perverse incentives. This pheno ...

, with insurers cutting benefits to lower premiums." The establishment of essential health benefits "set a standard for insurance. Anything below that is not true health insurance." The EHB requirement came into effect on January 1, 2014. Revision and repeal of essential health benefits coverage was proposed in the Republican part American Health Care Act of 2017. House

Freedom Caucus The Freedom Caucus, also known as the House Freedom Caucus, is a congressional caucus consisting of Republican Party (United States), Republican members of the United States House of Representatives. It is generally considered to be the most Cons ...

members lobbied during legislation discussion with House Speaker

Paul Ryan Paul Davis Ryan (born January 29, 1970) is an American politician who served as the List of Speakers of the United States House of Representatives, 54th speaker of the United States House of Representatives from 2015 to 2019. A member of the ...

to remove EHBs as a condition for approval of the AHCA bill.

Comparison with minimum essential coverage

Essential health benefits should not be confused with ''minimum essential coverage'' (''MEC''). MEC is the minimum amount of coverage that an individual must carry to meet the individual health insurance mandate, while EHBs are a set of benefits that qualified health plans (QHPs) must offer.Susan Grassli & Lisa Klinger
Understanding the Difference between Minimum Essential Coverage, Essential Health Benefits, Minimum Value, and Actuarial Value
Leavitt Group (January 27, 2014). MEC is a low threshold; many forms of coverage that do not provide essential health benefits are nevertheless considered minimum essential coverage.

Notes

Sources

*Sara Rosenbaum, Joel Teitelbaum & Katherine Hayes
The Essential Health Benefits Provisions of the Affordable Care Act: Implications for People with Disabilities
,

(March 2011). *Justin Giovannelli, Kevin W. Lucia & Sabrina Corlette
Implementing the Affordable Care Act: Revisiting the ACA’s Essential Health Benefits Requirements
Commonwealth Fund (October 2014).

External links

Essential Health Benefits
from HealthCare.gov
Information on Essential Health Benefits (EHB) Benchmark Plans
from the Consumer Information and Insurance Oversight of the

Centers for Medicare and Medicaid Services The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer ...

{{PPACA Affordable Care Act Healthcare reform legislation in the United States Health insurance in the United States