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Updated July 6, 2016
The Essential Health Benefits (EHB)
Overview
base their benefits packages in terms of the scope of
The Patient Protection and Affordable Care Act (ACA; P.L.
benefits offered (see Figure 1). These reference plans are
111-148, as amended) requires all non-grandfathered health
known as EHB-benchmark plans.
plans in the non-group and small-group private health
insurance markets to offer a core package of health care
For the 2014-2016 coverage years, the process required
services, known as the essential health benefits (EHB). The
each state to select an EHB-benchmark plan that was based
ACA does not specifically define this core package.
on plans available in the 2012 coverage year. For the 2017
Instead, it lists 10 categories from which benefits and
coverage year, the process requires each state to update its
services must be included (see Figure 1) and requires the
EHB-benchmark plan based on plans available in the 2014
Secretary of the Department of Health and Human Services
coverage year. A state selects a benchmark plan among (1)
(HHS) to further define the EHB.
the state’s small-group market health plans; (2) the state’s
state employee health benefit plans; (3) Federal Employees
Figure 1. Overview of the EHB Process
Health Benefits (FEHB) plans; or (4) the state’s commercial
non-Medicaid health maintenance organization (HMO).
Figure 2 maps the types of benchmark plans selected by
each state.
Figure 2. State Selection of EHB-Benchmark Plans,
2014-2017
Source: CRS analysis of individual state EHB-benchmark plan
summaries provided by the Centers for Medicare & Medicaid
Source: Congressional Research Service (CRS) analysis of the
Services, Information on Essential Health Benefits (EHB) Benchmark
essential health benefit (EHB) process based on 45 C.F.R. §156.100-
Plans, at http://www.cms.gov/CCIIO/Resources/Data-Resources/
115.
ehb.html as of June 15, 2016.
EHB for 2014-2017
Supplementing EHB-Benchmark Plans
State Selection of EHB-Benchmark Plans
According to the regulations, the EHB-benchmark plan had
to provide coverage for all 10 EHB categories. If the
The HHS Secretary outlined a process in which each state
selected benchmark plan did not include items or services
identified a single plan to serve as a reference plan on
within a category, the plan had to be supplemented.
which most non-group and small-group market plans must
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The Essential Health Benefits (EHB)
Generally, if an EHB-benchmark plan did not cover 1 or
Figure 3. Applicability of EHB Requirements to
more of the 10 EHB categories, the state supplemented the
Health Plans
EHB-benchmark plan by adding that particular category in
its entirety from another benchmark plan option.
Inclusion of State Benefit Mandates
Prior to the passage of the ACA, many states had laws,
known as state benefit mandates, that required health plans
to cover certain health care services, health care providers,
and/or dependents. A state may require non-group and
small-group plans to cover these state benefit mandates in
addition to the EHB. Moreover, any state benefit mandates
enacted on or before December 31, 2011, are considered to
be part of the EHB.
Nonetheless, in addition to covering the EHB, states may
Source: CRS analysis of 42 U.S.C. §18021 and 42 U.S.C. §18022.
choose to impose additional benefit mandates. If a state
Notes: This figure is not an exhaustive list of existing plan types.
decides to impose additional benefits, the state itself must
Limited exceptions may apply.
defray the cost of those benefits for plans offered in the
health insurance exchanges (i.e., marketplaces in which
EHB and Other ACA Provisions
individuals and small businesses can shop for and purchase
private health insurance coverage).
Cost Sharing
The ACA imposes an annual cap on consumer cost sharing
Variation in EHB Coverage
for the EHB. The ACA specifies that the limits work in two
Because each state selects its own EHB-benchmark plan,
ways: they prohibit (1) applying deductibles to preventive
there is considerable variation in EHB coverage from state
health services and (2) annual out-of-pocket limits that
to state. This variation occurs in terms of specific covered
exceed existing limits in the tax code. The cost-sharing
services as well as in terms of amount, duration, and scope.
limits apply only to in-network benefits. In 2016, the cost-
For example, some state EHB-benchmark plans may
sharing limits are $6,850 for an individual plan and $13,700
include bariatric surgery as a covered service whereas other
for a family plan. For 2017, the cost-sharing limits are
state EHB-benchmark plans may not cover bariatric
$7,150 for an individual plan and $14,300 for a family plan.
surgery.
Lifetime and Annual Dollar Limits
In addition to EHB variation by state, benefit coverage
Prior to the ACA, plans generally were able to set lifetime
among plans within a state may differ. States may allow
and annual limits—dollar limits on how much the plan
non-group and small-group market plans that offer the EHB
would spend for covered health benefits either during the
to substitute benefits. A benefit may be substituted if the
entire period an individual was enrolled in the plan (lifetime
substitution is equivalent to the benefit being replaced and
limits) or during a plan year (annual limits). The ACA
is made within the same EHB category. For example, a plan
prohibited both lifetime and annual limits on the EHB.
could offer coverage of up to 10 physical therapy visits and
Plans are permitted to place lifetime and annual limits on
up to 20 occupational therapy visits as a substitute for EHB-
covered benefits that are not considered EHB, to the extent
benchmark plan coverage of up to 20 physical therapy visits
that such limits are permitted by federal and state law.
and 10 occupational therapy visits, assuming other criteria
are met.
Minimum Essential Coverage
Applicability of EHB Requirements to
The EHB requirement differs from minimum essential
Health Plans
coverage. Minimum essential coverage is a term defined in
the ACA and its implementing regulations that refers to the
Generally, non-group and small-group market health plans
individual mandate, or the ACA requirement that most
are required to offer the EHB. This requirement applies to
individuals must have health insurance coverage for
non-group and small-group plans offered both inside and
themselves and their dependents or potentially pay a
outside the exchanges. Additional plan types are subject to
penalty for noncompliance. The definition of minimum
the EHB; examples of these plan types include qualified
essential coverage does not refer to minimum benefits but
health plans (e.g., multistate plans or child-only plans) and
rather includes most private and public coverage.
catastrophic plans (see Figure 3).
For additional information, see CRS Report R44163, The
Certain health plans are not subject to the EHB
Patient Protection and Affordable Care Act’s Essential
requirements. For example, grandfathered health plans
Health Benefits (EHB), by Namrata K. Uberoi.
(health insurance plans that were in existence and in which
at least one person was enrolled on the date of the ACA’s
Vanessa C. Forsberg, Analyst in Health Care Financing
enactment) are not subject to the EHB requirements as long
as they maintain their grandfathered status. This exclusion
IF10287
includes non-group and small-group grandfathered health
plans (see Figure 3).
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The Essential Health Benefits (EHB)
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
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