What Services/Benefits Must Plans Cover?

Last updated: October 7, 2015

"Essential Health Benefits"

After January 1, 2014, new plans sold in the individual and small group market must cover a comprehensive set of benefits known as essential health benefits.

(This includes plans sold through the Health Insurance Marketplace and SHOP Marketplace for Small Businesses, and most plans sold in the market outside the exchange.)

These essential health benefits include the following:

  • Ambulatory services (doctor’s office visits and outpatient services)

  • Emergency services

  • Hospitalization

  • Maternity and newborn care

  • Mental health and substance abuse disorder services, including behavioral health treatment

  • Prescription drugs

  • Rehabilitative and habilitative services and devices

  • Laboratory services

  • Preventive and wellness services, including chronic disease management

  • Pediatric services, including oral and vision care

For more detailed information about essential health benefits in the Health Insurance Marketplace, visit the NAIC website at http://www.naic.org/index_health_reform_section.htm under Essential Health Benefits Data from The Center for Consumer Information and Insurance Oversight (CCIIO).

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