Policy Examples

  • Under the Affordable Care Act (ACA) individual and group plans must cover 10 categories of services health insurance plans. Access to coverage with Essential Health Benefits (EHB) as a baseline is available in all 50 states through the ACA. source
  • Under the Affordable Care Act, self-insured group health plans, large group market health plans, and grandfathered health plans are not required to offer EHB. However, the prohibition in the Public Health Service Act, Section 2711, imposes annual and lifetime dollar limits on EHB does apply to self-insured group health plans, large group market health plans, and grandfathered group market health plans. source
  • The ACA’s focus on prevention includes smoking cessation efforts as a required benefit. Tobacco cessation as a federally guided preventive service defined as four sessions of individual, group and phone counseling, 90 days of all FDA-approved smoking cessation medications, 2 quit attempts per year, no prior authorization for treatments, and no cost-sharing. source
  • The Affordable Care Act, Section 4103, requires that a health risk assessment be included in the annual wellness visit benefit authorized for Medicare beneficiaries under the Act. source
  • According to the 1967 Security Act Amendments,  all children under 21 enrolled in Medicaid are entitled to the Early and Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit. This benefit provides preventive care for children for the purpose of discovering and treating childhood health conditions before they become serious or disabling. source

Outcome Evidence

  • Research asserts that downstream costs will increase if Essential Health Benefit (EHB) requirements are loosened and people are not insured for important care. source
  • A 2017 report published by Milliman found that removing Essential Health Benefits would likely result in lower premiums due to associated actuarial adjustment from less services and plan migration of healthy people moving to plans that offer less services. source
  • In 2014, over 40 million children were eligible for EPSDT, however under 60% of children received at least one screening. source

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