The Affordable Care Act (ACA) identified ten categories of services and items to be included in essential health benefits (EHBs), and specified that the scope of EHBs must be equal to the scope of benefits provided under a typical employer plan. The ten categories include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

A white paper issued in December by the Department of Health and Human Services’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) found there is little variation in services covered by small group products and state and federal employee plans. Much of the variation in value and benefit costs instead pertains to cost sharing, as opposed to covered services and items.

The paper addresses four points. First, it identifies the categories of items and services included under EHB. Second, it suggests that small group products and State and Federal employee plans cover similar services. Third, it reports that only a few specific services appear to vary across and within markets. Fourth, it highlights that coverage in some of the statutory EHB categories, such as behavioral health treatment, habilitative services, and pediatric oral and vision services, are limited.

HHS issued a guidance bulletin in December, saying that it intends to allow states to use existing health plans in their states as benchmarks for “essential health benefits” (EHBs) that must be offered by “non-grandfathered” individual and small group plans that went into effect after the enactment of the ACA. The EHB requirement is also applicable to plans modeled on Medicaid benchmarks and Basic Health Program (BHP) plans.