Updated July 6, 2016
The Essential Health Benefits (EHB)
The Patient Protection and Affordable Care Act (ACA; P.L.
111-148, as amended) requires all non-grandfathered health
plans in the non-group and small-group private health
insurance markets to offer a core package of health care
services, known as the essential health benefits (EHB). The
ACA does not specifically define this core package.
Instead, it lists 10 categories from which benefits and
services must be included (see Figure 1) and requires the
Secretary of the Department of Health and Human Services
(HHS) to further define the EHB.
Figure 1. Overview of the EHB Process
base their benefits packages in terms of the scope of
benefits offered (see Figure 1). These reference plans are
known as EHB-benchmark plans.
For the 2014-2016 coverage years, the process required
each state to select an EHB-benchmark plan that was based
on plans available in the 2012 coverage year. For the 2017
coverage year, the process requires each state to update its
EHB-benchmark plan based on plans available in the 2014
coverage year. A state selects a benchmark plan among (1)
the state’s small-group market health plans; (2) the state’s
state employee health benefit plans; (3) Federal Employees
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
Figure 2. State Selection of EHB-Benchmark Plans,
Source: Congressional Research Service (CRS) analysis of the
essential health benefit (EHB) process based on 45 C.F.R. §156.100115.
EHB for 2014-2017
State Selection of EHB-Benchmark Plans
The HHS Secretary outlined a process in which each state
identified a single plan to serve as a reference plan on
which most non-group and small-group market plans must
Source: CRS analysis of individual state EHB-benchmark plan
summaries provided by the Centers for Medicare & Medicaid
Services, Information on Essential Health Benefits (EHB) Benchmark
Plans, at http://www.cms.gov/CCIIO/Resources/Data-Resources/
ehb.html as of June 15, 2016.
Supplementing EHB-Benchmark Plans
According to the regulations, the EHB-benchmark plan had
to provide coverage for all 10 EHB categories. If the
selected benchmark plan did not include items or services
within a category, the plan had to be supplemented.
The Essential Health Benefits (EHB)
Generally, if an EHB-benchmark plan did not cover 1 or
more of the 10 EHB categories, the state supplemented the
EHB-benchmark plan by adding that particular category in
its entirety from another benchmark plan option.
Figure 3. Applicability of EHB Requirements to
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
choose to impose additional benefit mandates. If a state
decides to impose additional benefits, the state itself must
defray the cost of those benefits for plans offered in the
health insurance exchanges (i.e., marketplaces in which
individuals and small businesses can shop for and purchase
private health insurance coverage).
Variation in EHB Coverage
Because each state selects its own EHB-benchmark plan,
there is considerable variation in EHB coverage from state
to state. This variation occurs in terms of specific covered
services as well as in terms of amount, duration, and scope.
For example, some state EHB-benchmark plans may
include bariatric surgery as a covered service whereas other
state EHB-benchmark plans may not cover bariatric
In addition to EHB variation by state, benefit coverage
among plans within a state may differ. States may allow
non-group and small-group market plans that offer the EHB
to substitute benefits. A benefit may be substituted if the
substitution is equivalent to the benefit being replaced and
is made within the same EHB category. For example, a plan
could offer coverage of up to 10 physical therapy visits and
up to 20 occupational therapy visits as a substitute for EHBbenchmark plan coverage of up to 20 physical therapy visits
and 10 occupational therapy visits, assuming other criteria
Applicability of EHB Requirements to
Generally, non-group and small-group market health plans
are required to offer the EHB. This requirement applies to
non-group and small-group plans offered both inside and
outside the exchanges. Additional plan types are subject to
the EHB; examples of these plan types include qualified
health plans (e.g., multistate plans or child-only plans) and
catastrophic plans (see Figure 3).
Certain health plans are not subject to the EHB
requirements. For example, grandfathered health plans
(health insurance plans that were in existence and in which
at least one person was enrolled on the date of the ACA’s
enactment) are not subject to the EHB requirements as long
as they maintain their grandfathered status. This exclusion
includes non-group and small-group grandfathered health
plans (see Figure 3).
Source: CRS analysis of 42 U.S.C. §18021 and 42 U.S.C. §18022.
Notes: This figure is not an exhaustive list of existing plan types.
Limited exceptions may apply.
EHB and Other ACA Provisions
The ACA imposes an annual cap on consumer cost sharing
for the EHB. The ACA specifies that the limits work in two
ways: they prohibit (1) applying deductibles to preventive
health services and (2) annual out-of-pocket limits that
exceed existing limits in the tax code. The cost-sharing
limits apply only to in-network benefits. In 2016, the costsharing limits are $6,850 for an individual plan and $13,700
for a family plan. For 2017, the cost-sharing limits are
$7,150 for an individual plan and $14,300 for a family plan.
Lifetime and Annual Dollar Limits
Prior to the ACA, plans generally were able to set lifetime
and annual limits—dollar limits on how much the plan
would spend for covered health benefits either during the
entire period an individual was enrolled in the plan (lifetime
limits) or during a plan year (annual limits). The ACA
prohibited both lifetime and annual limits on the EHB.
Plans are permitted to place lifetime and annual limits on
covered benefits that are not considered EHB, to the extent
that such limits are permitted by federal and state law.
Minimum Essential Coverage
The EHB requirement differs from minimum essential
coverage. Minimum essential coverage is a term defined in
the ACA and its implementing regulations that refers to the
individual mandate, or the ACA requirement that most
individuals must have health insurance coverage for
themselves and their dependents or potentially pay a
penalty for noncompliance. The definition of minimum
essential coverage does not refer to minimum benefits but
rather includes most private and public coverage.
For additional information, see CRS Report R44163, The
Patient Protection and Affordable Care Act’s Essential
Health Benefits (EHB), by Namrata K. Uberoi.
Vanessa C. Forsberg, Analyst in Health Care Financing
The Essential Health Benefits (EHB)
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
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF10287 · VERSION 7 · UPDATED