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-transitional small group qualified health plans.

EHBs are determined on a state-by-state basis. Michigan’s EHB categories are:

• Ambulatory patient services
• Emergency services
• Hospitalization
• 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

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.