Essential Health Benefits

ERISA self-funded plans do not have to include 10 categories of benefits known as Essential Health Benefits (EHBs). However, if such self-funded plans do include EHBs for plan years beginning on or after Jan. 1, 2014, they are prohibited by PPACA from imposing lifetime or annual dollar limits on these benefits.

  1. ambulatory patient services
  2. emergency services
  3. hospitalization
  4. maternity and newborn services
  5. mental health and substance abuse, including behavioral health treatment
  6. prescription drugs
  7. rehabilitative and habilitative* services and devices
  8. laboratory service
  9. prevention and wellness services and chronic disease management
  10. pediatric services (including oral and vision care)

*For the 2016 plan year, HHS adopted a uniform definition of habilitative services, an Essential Health Benefit, for when the state-selected benchmark plan does not include these services and the state has not enacted its own definition. This definition is also found in the Uniform Glossary of Health and Coverage and Medical Terms: “Healthcare services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”