Essential Health Benefits

AAA

DEFINITION of 'Essential Health Benefits'

A set of benefit requirements that must be included in certain health insurance plans. Essential health benefits comprise 10 general benefit categories, which must be covered in health insurance plans offered to individuals or through the small-group market to employers with 50 or fewer employees, under the Patient Protection and Affordable Care Act (ACA), the U.S. health reform law signed into law by President Obama in March 2010.

INVESTOPEDIA EXPLAINS 'Essential Health Benefits'

A health-care expense is “covered” if your plan benefits are applied to the item or service. For example, if chiropractic care is a covered benefit on a certain policy, plan benefits – such as a $25 copayment – would apply to chiropractic visits. In contrast, if chiropractic care is not a covered benefit, any expenses incurred through chiropractic visits would have to be paid entirely out-of-pocket, and the expenses would not count toward the policy’s deductible or out-of-pocket limit. While plans can offer more comprehensive benefits, essential health benefits constitute the minimum benefits for plans offered to individuals and through the small-group market to employers with 50 or fewer employees. The essential health benefits are:

  •  Ambulatory patient services – Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center.
  •  Emergency services – Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness.
  •  Hospitalization Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board.
  •  Laboratory services – Testing provided to help a doctor diagnose an injury, illness or condition, and to monitor the effectiveness of a particular treatment.
  •  Maternity and newborn care – Care that women receive during pregnancy (prenatal care), throughout labor and delivery, and post-delivery; and care for newborn babies.
  •  Mental health services and addiction treatment – Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder.
  •  Rehabilitative services and devices – Rehabilitative and habilitative services and devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition.
  • Pediatric services Care provided to infants and children, including well-child visits and recommended vaccines and immunizations, dental and vision care.
  •  Prescription drugs – Medications prescribed by a doctor to treat an illness or condition.
  •  Preventive and wellness services and chronic disease treatment – Physicals, immunizations and cancer screenings designed to prevent or detect certain medical conditions, and care for chronic conditions.
RELATED TERMS
  1. Children’s Health Insurance Program ...

    A medical coverage source for individuals under age 19 whose ...
  2. Uniform Policy Provisions, Health ...

    A provision that states that insurance companies must use standard ...
  3. Universal Health Care Coverage

    An organized healthcare system that provides healthcare benefits ...
  4. Commercial Health Insurance

    A type of health insurance that covers medical expenses and disability ...
  5. National Organization Of Life And ...

    NOLHGA is a voluntary organization of U.S. life- and health-insurance ...
  6. Group Health Insurance Plan

    An insurance plan that provides healthcare coverage to a select ...
Related Articles
  1. Insurance

    What You Need To Know About COBRA Health Insurance

    We go through everything you need to know about COBRA so that you can decide if it's right for you.
  2. Home & Auto

    The History Of Insurance

    The first written policy appeared in Hammurabi's Code. Find out how it evolved from there.
  3. Home & Auto

    Understanding Lender-Required Flood Insurance

    Having to buy flood insurance shouldn't be a surprise. Find out what you need to know when purchasing or refinancing a house.
  4. Home & Auto

    Concierge Healthcare: The Pros and Cons Of Having A Doctor On Call

    Concierge healthcare can mean extra attention from your doctor when you need it, but it isn't the best substitute for health insurance.
  5. Key metrics suggest that it could be time to invest in healthcare facilties.
    Fundamental Analysis

    Investing In Healthcare Facilities

    Read on to learn about how to value heathcare sector stocks.
  6. Insurance

    5 Things You Should Know About The New Health Insurance Marketplace

    Here are five things you should know about the new Health Insurance Marketplace (AKA Health Insurance Exchange), which launches on October 1.
  7. Fundamental Analysis

    How To Value An Insurance Company

    In the insurance space, accurate predictions of metrics such as ROE are important, and paying a low P/B can help put the odds in investors' favor.
  8. Investing Basics

    What Dividends Say About Stock Health

    Dividend payments may reveal information about the future prospects of a company.
  9. Personal Finance

    Comparing Health Savings And Flexible Spending Accounts

    When it comes to medical expenses, there are many accounts that provide tax advantages. We look at two commonly seen among employees.
  10. Insurance

    What You Need To Know About Student Health Insurance

    Before heading off to college, read up on health insurance plans.

You May Also Like

Hot Definitions
  1. Multinational Corporation - MNC

    A corporation that has its facilities and other assets in at least one country other than its home country. Such companies ...
  2. SWOT Analysis

    A tool that identifies the strengths, weaknesses, opportunities and threats of an organization. Specifically, SWOT is a basic, ...
  3. Simple Interest

    A quick method of calculating the interest charge on a loan. Simple interest is determined by multiplying the interest rate ...
  4. Special Administrative Region - SAR

    Unique geographical areas with a high degree of autonomy set up by the People's Republic of China. The Special Administrative ...
  5. Annual Percentage Rate - APR

    The annual rate that is charged for borrowing (or made by investing), expressed as a single percentage number that represents ...
  6. Free Carrier - FCA

    A trade term requiring the seller to deliver goods to a named airport, terminal, or other place where the carrier operates. ...
Trading Center