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Fact Sheet: Essential Health Benefits

The Affordable Care Act (ACA) requires that Qualified Health Plans (QHPs) offered in the individual and small group markets, both inside and outside of the new Health Insurance Marketplace (or “Exchange”), cover a core package of healthcare services known as Essential Health Benefits (EHBs). Plans that are in compliance with the new rules must cover – at a minimum – the following 10 general categories of EHBs:

  1. Ambulatory patient services;
  2. Emergency services;
  3. Hospitalization;
  4. Maternity and newborn care;
  5. Mental health and substance use disorder services, including behavioral health treatment;
  6. Prescription drugs;
  7. Rehabilitative and habilitative services and devices;
  8. Laboratory services;
  9. Preventive and wellness services and chronic disease management;
  10. Pediatric services, including oral and vision care.

QHPs must cover at least some benefits within each of these ten categories in order to be certified and offered in their state’s Health Insurance Marketplace. Each state’s insurance officials can look to an existing benchmark plan in their state to assess whether QHPs are offering a meaningful amount of benefits in each category.  Some states are regulating which specific services QHPs in their state must offer within each category.

One would look for cochlear implantation coverage under Rehabilitative and Habilitative Services and Devices, category #7 above.

 

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