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  • Home Employers Industry Insights Informed on Reform Essential Health Benefits (EHBs)

    Essential Health Benefits

    Understand what plans must cover these health benefits, and how various plans are impacted by respective cost sharing limits and rules.

    The Affordable Care Act (ACA) requires fully insured small group and individual health plans (both on and off the public exchange/Marketplace) provide coverage for a core package of health care services, known as "essential health benefits" (EHBs). This rule is intended to balance comprehensiveness and affordability for consumers by ensuring essential services are covered and consumer out-of-pocket expenses are limited.

    EHB categories

    In addition to the standard 10 EHB categories detailed below, states may include additional benefit requirements under their own state regulations or within a state's selected benchmark plan.

    1. Ambulatory patient services
    2. Emergency services
    3. Hospitalization
    4. Maternity and newborn care
    5. Mental health and substance abuse 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

    Any health plan that covers EHBs must cover these benefits with no annual limits or lifetime maximums. This includes self-insured and large group plans (having 51 or more employees). Effective January 1, 2017, plans that offer out-of-network benefits on EHBs may no longer place limits or maximums on those benefits.

    Out-of-pocket limits on EHBs

    Out-of-pocket (OOP) consumer spending, which typically includes deductibles, copays and coinsurance, is limited for in-network essential health benefit services. The OOP spending limits are adjusted annually and can be found on our Cost Sharing page.

    State benchmark plans

    The Department of Health and Human Services (HHS) regulates EHBs based on State-specific EHB-benchmark plans. The Final 2019 HHS Notice of Benefits and Payment Parameters established standards for states, giving them greater flexibility in choosing to update their EHB-benchmark plans.

    It's important for employers who sponsor group health plans to understand which benchmark plan they must follow so they know which benefits cannot have annual or lifetime limits. The state benchmark plan is determined differently based on the plan's funding type:

    • Employers that self-insure their plans can choose a state to use for their benchmark plan.
    • Employers with insured plans must use the benchmark plan of employer's contract/situs state, except for HMO plans which must follow the HMO plan state.

    For more information on state benchmark plans, visit Information on Essential Health Benefits (EHB) Benchmark Plans.

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    Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT). The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by The Cigna Group Intellectual Property, Inc.

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