In plain words
Essential health benefits are a set of covered services that most health plans must include under the . The list has ten categories. They include hospital care, prescriptions, mental health and substance use care, and maternity and newborn care. Maternity and newborn care is one of the ten, so plans sold on the marketplace must cover pregnancy care and the birth. The list applies to individual and small-group plans, not to every kind of coverage. States can add to the list, and the details are set by federal and state rules. The categories do not mean every service is free. Deductibles, copayments, and networks still apply. The list sets what must be covered, not what it costs.
The deeper version
Essential health benefits are defined in section 1302(b) of the Affordable Care Act as ten categories of items and services, including ambulatory care, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, and pediatric services including oral and vision care. The benchmark is set through state-selected benchmark plans, and states may add benefits with cost implications. Maternity care as a required category is one reason pregnancy services are covered in nongrandfathered individual and small-group plans. Debates concern benchmark design, state mandates, and whether cost-sharing limits protect pregnant patients in practice.
Where it comes up
- Medi-Cal, Covered California, and insurance in pregnancyCalifornia: Leave, Money, and Paperwork
- Birth certificate, Social Security, and adding the baby to insuranceCalifornia: Leave, Money, and Paperwork
- What insurance usually covers: pumps, lactation visits, pelvic floor PTCalifornia: Leave, Money, and Paperwork
- Doula coverage under Medi-CalCalifornia: Leave, Money, and Paperwork
What mothers here say about essential health benefits
No one has posted under this term yet.
Sources
- US Congress — Patient Protection and Affordable Care Act of 2010, section 1302(b)
- Centers for Medicare and Medicaid Services — Essential health benefits benchmark plan guidance