Essential health benefits
Services that small group plans must cover
Essential health benefits are categories of health care services that must be covered by all non-grandfathered1 small group qualified health plans.
EHBs are determined on a state-by-state basis. Michigan’s EHB categories are:
- Ambulatory patient services
- Emergency services
- Laboratory services
- Maternity and newborn care
- Mental health and substance use disorder services
- Pediatric services, including oral and vision care
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices
1Grandfathered group health plans are those that were in place on March 23, 2010, when the Affordable Care Act was enacted. They are exempt from some ACA requirements. However, to maintain grandfathered status, a plan cannot reduce or eliminate benefits, increase employee cost-sharing above certain thresholds, or reduce the employer share of the premium payment. Once a plan loses its grandfathered status, it must comply with all applicable requirements of the law. It is the employer group’s responsibility to determine if the plan is grandfathered.
Are all employers required to provide EHBs to their employees?
No. Large groups with fully insured, self-funded and grandfathered plans are not required to cover EHBs.
What is a qualified health plan?
QHPs are Affordable Care Act-compliant plans that, in addition to covering EHBs, must follow established limits on cost-sharing. They are grouped into metal tiers based on the percentage of health care costs the plans cover.