Essential Health Benefits Under the AHCA (ACA Replacement)

What are Essential Health Benefits (EHB)?

The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten 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.
— The Center for Consumer Information & Insurance Oversight - https://www.cms.gov/cciio/resources/data-resources/ehb.html

 

Prior to the ACA, health insurance was not required to cover the benefits above.  Health insurance could exclude prescriptions, pediatric services,  hospitalization, maternity and prenatal care and mental health services.  The EHBs are also tied to the limits on consumer spending for these services.  Currently, out of pocket costs for an individual cannot be more than $7,150 and for families the cost cannot be more than $14,300. Under the AHCA, states could apply for waivers and the costs for EHBs would no longer be capped.   

 

Let's compare the benefits in the ACA to the AHCA. 

While it is true that your monthly premium might be less under the AHCA, if you live in a state that gets a waiver, all the EHB may not be included in your health plan. If your health situation changes, you could pay much more for services that are currently included in all health plans.  

An Example

For example, a state could remove coverage for maternity or newborn care from the essential health benefits. Prior to the Affordable Care Act, most health plans did not cover maternity care, and pregnant women would have to pay the full cost of prenatal care, labor and delivery. That could happen again. 

In fact, women's healthcare is particularly targeted. Under the AHCA, Planned Parenthood would not be able to get Medicaid reimbursals for pap smears, birth control, or cancer screenings. Since Planned Parenthood is the largest reproductive health care provider in the country, it is likely that removing them as a provider--with or without removing the essential health benefit of contraception--will mean many more unintended pregnancies. For middle-income women, over the income cap for Medicaid, the birth and expenses would not be capped so you could pay $15,000 or more for a birth with complications.

The AHCA--the "replacement" for the ACA--goes next to the U.S. Senate. If you support comprehensive and affordable health care, let your senator know that you oppose the repeal of the ACA. 

Have questions?  Ask them in the comments section and we will do our best to answer. Call 734-544-3030 or Walk-in to the Washtenaw Health Plan office Monday - Friday from 9am - 4pm.   

-Meredith Buhalis and Ruth Kraut

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