HHS Bulletin Proposes Standards for ACA Essential Health Benefits

In mid-December, the U.S. Department of Health and Human Services (HHS) issued the Essential Health Benefits Bulletin (EHBB).

HHS did not issue a detailed rule on what “essential benefits” must be included in the new health exchanges and are deferring to the states on what essential health benefits package should look like. They issued a pre-regulatory bulletin that says states will have the flexibility to choose from four different coverage options already available in their states, an approach that could result in different benefits throughout the country. HHS officials said this bulletin will guide them as they write the regulations in the future.


The bulletin provides helpful background statutory information and describes HHS' intended approach toward developing regulations defining “essential health benefits” (EHB). As required under the Patient Protection and Affordable Care Act (ACA), the essential benefits package will establish the minimum that must be covered by certain health plans, including those participating in state-based health insurance exchanges.

Non-grandfathered plans in the individual and small group markets both inside and outside of the Exchanges, Medicaid benchmark and benchmark-equivalent, and Basic Health Programs must cover the EHB beginning in 2014. In ACA, 1 Section 1302(b)(1) provides that EHB include items and services within the following 10 benefit categories:  1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management and (10) pediatric services, including oral and vision care.

If a state selects a plan that does not cover all of those categories, it must look at other plans to fill the gaps. States could modify coverage within a benefit category if it doesn’t reduce the value of the coverage.

Self-insured group health plans, health insurance coverage offered in the large group market, and grandfathered health plans are not required to cover the essential health benefits.