Essential health benefits are 10 categories of healthcare services that insurance plans must cover under the Affordable Care Act. They apply to all non-grandfathered individual and small group market plans, including those sold through the Health Insurance Marketplace. The goal is straightforward: no matter which plan you buy in these markets, it has to cover a baseline set of services so you’re not left exposed to major medical costs.
The 10 Categories
Every qualifying plan must include items and services in at least these ten areas:
- Ambulatory patient services (outpatient care you receive without being admitted to a hospital)
- Emergency services
- Hospitalization
- 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 oral and vision care
These categories are broad by design. The specific services, visit limits, and covered treatments within each category vary by state, because each state selects a “benchmark plan” that defines the details. That means your plan in Texas may cover a slightly different list of physical therapy visits or prescription drugs than a plan in New York, even though both must check all ten boxes.
How Preventive Care Works
Preventive and wellness services get special treatment. Most health plans must cover a defined set of preventive services, like immunizations, cancer screenings, and blood pressure checks, at zero cost to you when you see an in-network provider. You won’t pay a copay or coinsurance for these services, even if you haven’t met your deductible yet. The covered list is organized into three groups: services for all adults, services specifically for women, and services for children.
This is one of the most practically useful parts of essential health benefits. Annual wellness visits, cholesterol screening, certain vaccines, and depression screening are all typically included at no out-of-pocket cost.
Mental Health Parity
Mental health and substance use disorder coverage comes with an important legal protection called parity. Under the Mental Health Parity and Addiction Equity Act, your plan cannot impose stricter financial requirements or treatment limits on mental health and substance use services than it does on comparable medical and surgical benefits. If your plan charges a $30 copay for an in-network specialist visit, it can’t charge $50 for an in-network therapy session.
This applies to copays, coinsurance, deductibles, and out-of-pocket limits. It also extends to less obvious restrictions like prior authorization requirements, step therapy protocols, and other management tools. Plans must apply these requirements no more stringently to mental health benefits than they do to medical benefits. Deductibles and out-of-pocket maximums must combine medical and mental health spending together rather than tracking them separately.
Rehabilitative vs. Habilitative Services
These two terms sound similar but cover different situations. Rehabilitative services help you regain skills or functioning you lost because of an illness, injury, or disability. Think physical therapy after knee surgery or speech therapy after a stroke. Habilitative services help you develop skills you haven’t yet acquired. A child who isn’t walking or talking at the expected age might receive habilitative physical or speech therapy. Adults with conditions like cerebral palsy or intellectual disabilities also benefit from habilitative care.
Both types can include physical therapy, occupational therapy, speech-language pathology, and audiology services in inpatient or outpatient settings. Before the ACA, many individual plans didn’t cover habilitative services at all, leaving families of children with developmental delays or adults with lifelong disabilities to pay entirely out of pocket.
Prescription Drug Coverage
Plans must cover prescription drugs, but they don’t have to cover every drug on the market. The federal standard requires coverage of at least one drug in every category and class defined by the United States Pharmacopeia, or the same number of drugs in each category as the state’s benchmark plan, whichever is greater. In practice, this means your plan’s formulary (its list of covered drugs) will include options across a wide range of conditions, but you may need to work with your doctor to find a covered alternative if your specific medication isn’t on the list.
Pediatric Services and Dental Coverage
Pediatric services include a notable benefit that doesn’t exist for adults: mandatory dental and vision coverage for children. Plans must cover pediatric dental benefits for enrollees until at least the end of the month they turn 19, though states can extend that age upward. Pediatric vision care is similarly required.
For adults, dental coverage has historically been optional under essential health benefits. That’s changing. In 2025, CMS removed the regulatory prohibition on including routine adult dental services as an essential health benefit. This doesn’t automatically add adult dental to every plan. Instead, it allows states to update their benchmark plans to include routine non-pediatric dental coverage starting with the 2027 benefit year. Whether your state takes advantage of this option will depend on state-level decisions in the coming years.
Which Plans Must Comply
Essential health benefits apply to non-grandfathered health plans in the individual market (plans you buy on your own, including through the Marketplace) and the small group market (employers with 50 or fewer employees). These are the plans where the requirements have the most direct impact on what you’ll see in your coverage.
Several types of plans are not required to cover all 10 categories. Grandfathered plans, those that existed before the ACA was signed into law in March 2010 and haven’t made significant changes since, are exempt. Large employer plans (self-insured or fully insured covering more than 50 employees) are also not held to EHB requirements, though they must comply with other ACA provisions like preventive care coverage and the ban on annual and lifetime dollar limits on essential health benefits. Short-term health plans and health sharing ministries fall outside these rules entirely.
If you’re unsure whether your plan covers essential health benefits, look at the Summary of Benefits and Coverage document your insurer is required to provide. It breaks down what’s covered in each category and what your cost-sharing looks like for each type of service.