Essential Health Benefits (EHB)
All new major medical* plans include coverage for Essential Health Benefits (EHB). This includes the following categories which are not subject to annual dollar limitations:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision care
The degree to which all of these benefits are covered may vary by plan and by state.
Cost-sharing and coverage for out-of-pocket expenses
All new individual major medical plans correspond to a metallic level (also known as a metallic plan) or a catastrophic plan. Metallic plans have different cost-sharing attributes, also known as the actuarial value. Each metallic plan level covers a certain amount of out-of-pocket expenses – which includes the deductible, coinsurance and any copays on the plan, but does not include the premium.
For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs for the in-network essential health benefits, up to your out-of-pocket maximum.
Percentage of out-of-pocket expenses covered by each plan type (actuarial value):
- Bronze – 60%
- Silver – 70%
- Gold – 80%
- Platinum – 90%
How each of these plans cover the set amount of out-of-pocket expenses may vary. For example, there could be two bronze plans, but each one may have a different combination of deductible, coinsurance and copays that will still meet the 60 percent actuarial value of that plan type.
What this means to you
These changes ensure that all consumers will have access to comprehensive health insurance. However, it is important to note that expanded coverage is a factor that has impacted premium costs for these plans, along with all of the other changes that are going into effect.
Learn more about impacts to premium costs on major medical plans
*Applies to individual and small business fully-insured plans. Not all requirements apply to small business self–funded plans.
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