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Essential Health Benefits

The Affordable Care Act (ACA) identifies 10 broad categories of services that it requires certain health insurance plans to cover. Those services are called essential health benefits (EHBs). One of the categories of EHBs is rehabilitative and habilitative services and devices. The federal government allowed states to adopt an existing health plan as the model for coverage of EHBs, which it called a benchmark plan. A state’s benchmark plan serves as the model for the types of services that must be covered, as well as any quantitative limits on those services, such as visit limits. Therefore, each state’s EHBs can vary in terms of the particulars, such as what services are included under the rehabilitative services category and how many visits are permitted. To the extent that a state’s benchmark plan did not include all the EHBs, the state had to supplement it to ensure coverage of all services in each of the 10 categories. Because habilitative services were often excluded from health insurance coverage in the past, many benchmark plans did not reference them. In those cases, states were permitted to define coverage requirements for habilitation. In cases where states did not do so, insurers have to supplement benchmark plans to include coverage of habilitative services. The ACA requires all nongrandfathered individual and small group market plans to cover the EHBs. In addition, the EHBs must be covered for newly eligible populations in states that expand Medicaid eligibility pursuant to the ACA.

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