What Are Essential Health Benefits
Essential Health Benefits (EHBs) are ten categories of health services that all ACA-compliant insurance plans must cover. These ten categories are: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, preventive and wellness services, rehabilitation services and devices, laboratory services, and pediatric services including dental and vision care.
For government benefits applicants, EHBs matter because they set a minimum floor for what Medicaid and other state-administered health programs must cover. If you're applying for Medicaid or examining your coverage options after applying for SNAP, TANF, or WIC, understanding EHBs helps you know what medical services your plan will actually pay for. Many states use the EHB framework to define their Medicaid benefits package, meaning your coverage won't fall below these ten categories regardless of which state program you qualify for.
How EHBs Apply to Government Assistance Programs
- Medicaid: States must cover at least the ten EHB categories for adults and children. Some states cover additional services beyond EHBs, such as dental or vision for adults, but all must meet the ten-category minimum.
- SNAP, TANF, and WIC: These programs don't directly provide health insurance, but many state agencies automatically enroll SNAP and TANF applicants into Medicaid if they meet income thresholds. Your Medicaid coverage will include EHBs.
- Income thresholds: For 2024, Medicaid eligibility typically starts at 138 percent of the federal poverty level in expansion states (roughly $1,968 monthly income for a single adult), though some non-expansion states use lower thresholds around 100 percent. EHBs apply regardless of which income bracket you fall into.
- Application coordination: When you apply for SNAP at 130 percent of poverty, your state will often simultaneously check Medicaid eligibility. If approved, your Medicaid plan must include EHBs by law.
The Ten Categories Explained
- Ambulatory patient services: Doctor visits, urgent care clinics, and outpatient procedures you don't stay overnight for.
- Emergency services: Emergency room visits and emergency transportation via ambulance.
- Hospitalization: Inpatient hospital stays, including labor and delivery.
- Maternity and newborn care: Prenatal visits, delivery, and postpartum care for you and your newborn during the first 30 days.
- Mental health and substance use disorder services: Therapy, counseling, psychiatric medication management, and addiction treatment.
- Prescription drugs: Covered medications at pharmacies, though your plan may require copayments.
- Preventive and wellness services: Annual checkups, vaccinations, screenings, and contraception at no cost-sharing.
- Rehabilitation and devices: Physical therapy, occupational therapy, and medical equipment like wheelchairs or hearing aids.
- Laboratory services: Blood tests, imaging, X-rays, and diagnostic tests ordered by your doctor.
- Pediatric services including dental and vision: For children under 19, dental care and eye exams plus glasses are covered; adults' dental and vision coverage varies by state.
Common Questions
- Does my state Medicaid plan cover everything in the ten categories? Yes, every state Medicaid program must cover the ten EHBs as a baseline. However, coverage details like copayments, deductibles, and which drugs are included in the prescription drug category can vary by state. Contact your state Medicaid office or your caseworker for specifics on your plan.
- I'm applying for SNAP. Does that automatically give me health insurance with EHBs? SNAP itself is food assistance, not health insurance. However, if your income qualifies you for both SNAP and Medicaid, your state will enroll you in Medicaid, which covers EHBs. Your SNAP caseworker can tell you whether you also qualify for Medicaid during the application process.
- Are there costs even though EHBs must be covered? Preventive services like annual checkups and vaccinations are free. For other EHB services, you may pay copayments, deductibles, or coinsurance depending on your specific Medicaid plan. Check your state's Medicaid handbook or call your plan for cost-sharing details.