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Essential Health Benefits Plan

Explanation of Benefits

The District’s Essential Health Benefits Plan is a set of health care service categories that must be covered in certain health plans, starting in January 2014. The Affordable Care Act ensures that health plans offered in the individual and small group markets, both inside and outside of the District’s Health Benefit Exchange, provide a comprehensive package of items and services, known as essential health benefits.

Essential health benefits must include items and services within at least the following 10 categories:

  • ambulatory patient services;
  • 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;
  • and pediatric services, including oral and vision care.

Insurance policies must cover these benefits in order to be certified and offered in the exchange. All Medicaid state plans must cover these services by 2014.

Although the District has submitted their Essential Health Benefits Selection to the Center for Consumer Information and Insurance Oversight, the District and the Board will continue to refine the selection as further federal guidance is made available. You can view the proposals in the Essential Health Benefits Bulletin [PDF], which includes the proposed recommendations for benchmark insurance plans to be offered in the District’s Health Benefit Exchange.