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E is for Essential Health Benefits

For better or worse, health insurance has been in the news a lot lately, so we are continuing our series to help you understand different terms that may come up.

Today's topic is Essential Health Benefits.

When it comes to Health Insurance, it is nice to know what you are getting. It’s important to compare options and plans and networks, and by regulating essential benefits we can ensure that the plans that are offered will have some points of similarity.

When you buy a new car there are some things we have come to expect as standard: A steering wheel and four tires, safety features such as lights, airbags, and seat belts, seats for the driver and passengers, etc. There are things that are included in cars that may not define the car, but are rarely left out. Cup holders, Bluetooth connections for phones, and even a trunk may be nice but are not necessary. The brand, the color, and even the fuel type and range may be different, but most of us can agree on what a car is.

So what are the mandatory features of Health insurance? The Affordable Care Act identified 10 Essential Health Benefits that every plan must include in order to meet the federal mandate of coverage:

  1. Ambulatory patient services (outpatient care such as seeing a doctor)

  2. Emergency services

  3. Hospitalization

  4. Pregnancy, maternity, and newborn care

  5. Mental health and substance use disorder services

  6. Prescription drugs

  7. Rehabilitative and habilitative services and devices (such as PT and OT)

  8. Laboratory services

  9. Preventive care, wellness services and chronic disease management

  10. Pediatric services including oral and vision care (adult oral and vision care are excluded)

A lot of the discussion in the news is about gutting these benefits and reducing plans down to bare bones. Most health insurance plans already have a lot of exclusions such as cosmetic surgery, weight loss programs and vision/dental care for adults. What else can be cut? How many benefits can you strip away from a health insurance policy before it will no longer be considered health insurance by a reasonable consumer? Would you buy a car if you had to pay for all the safety features separately? How many things could you strip from a car and yet still call it a car? A car without a cup holder is still a car, but what if it had no wheels or engine? It may have the potential to be a working car, but it’s not able to fulfill its basic function of moving you from one point to another.

A health insurance plan without prescription drug coverage could still provide a lot of benefits, but is that really an insurance plan you would want? You may not be taking any drugs now, but what if you get hit in your car (without seatbelts or cupholder) and are gravely injured? Suddenly you are in the hospital and the doctor and surgery is covered, but none of the medication. Hmmm. Suddenly this plan isn’t so helpful. And what if you get an infection, or cancer, or diabetes?


Merriam-Webster defines insurance as:

b : coverage by contract whereby one party undertakes to indemnify or guarantee another against loss by a specified contingency or peril


The point of insurance is that we can’t plan ahead – life is uncertain and most of us don’t schedule peril into our daily lives. By defining essential health benefits, we can know what our health insurance plans cover. If a plan doesn’t cover doctor visits or hospitalization, is it really a health insurance policy?

Would you pay for an insurance policy that only covers you when you are healthy and have no medical needs? I wouldn't.

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