4.4 ACA Essential Health Benefits

ACA Essential Health Benefits

Quick Answer: Under the ACA, non-grandfathered individual and small-group health plans must cover ten Essential Health Benefits, cap in-network out-of-pocket spending at $10,600 (self-only) or $21,200 (family) in 2026, cover preventive care with no cost-sharing, and are sold in four metal tiers — Bronze 60%, Silver 70%, Gold 80%, and Platinum 90% actuarial value.

The Ten Essential Health Benefits

The ACA requires non-grandfathered individual and small-group health plans to cover ten Essential Health Benefits (EHBs):

1. Ambulatory patient services (outpatient care)
2. Emergency services
3. Hospitalization (surgery, overnight stays)
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
10. Pediatric services, including oral and vision care

These ten categories create a floor; states may specify the exact benchmarks within each category through an EHB-benchmark plan.

Out-of-Pocket Maximum

The ACA imposes an annual out-of-pocket maximum on in-network EHB spending. For 2026, the ACA OOP maximum is $10,600 for self-only coverage and $21,200 for family coverage. Once a covered person's cost-sharing (deductibles, copays, coinsurance) for in-network EHB care reaches this cap, the plan pays 100% of remaining in-network EHB expenses for the rest of the plan year. Note this ACA OOP maximum is distinct from the lower HDHP maximum OOP limits that gate HSA eligibility.

Preventive Care at No Cost-Sharing

ACA-compliant plans must cover recommended preventive care with no cost-sharing when delivered by an in-network provider. This includes:

• Evidence-based screening services rated A or B by the U.S. Preventive Services Task Force (USPSTF).
• Routine immunizations recommended by the CDC.
• Preventive care for women and children under HRSA guidelines.

This no-cost-sharing preventive rule is one of the most-tested ACA provisions on the A&H exam.

Metal Tiers and Actuarial Value

ACA individual and small-group plans are categorized into four metal tiers based on actuarial value (AV) — the percentage of total average costs for covered benefits that a plan pays:

Bronze plans have the lowest premiums and highest cost-sharing, while Platinum plans have the highest premiums and lowest cost-sharing. Silver plans are the only tier on which cost-sharing reductions (CSRs) are applied for households between 100% and 250% of the federal poverty level, raising the effective AV.

Why EHBs Matter

Before the ACA, individual and small-group plans frequently excluded maternity, mental health, prescription drugs, or pediatric dental coverage. The EHB requirement standardized the coverage floor, and the OOP maximum protected families from catastrophic medical spending. Together with the metal tiers, these rules make plan comparison possible across the marketplace.

EHB Benchmark Plans

Each state designates an EHB-benchmark plan — typically a popular small-group plan in that state — that defines the specific services and limits covered within each of the ten EHB categories. Plans sold in the state must cover benefits substantially equal to the benchmark. States may update their benchmark plan beginning in 2020 under federal rules, allowing them to tailor EHB coverage such as adding acupuncture or fertility treatments without expanding the overall scope.

Mental Health and Substance Use Disorder Parity

The EHB requirement works with the Mental Health Parity and Addiction Equity Act (MHPAEA): mental health and substance use disorder services must be covered at parity with medical/surgical benefits. That means quantitative treatment limits (visit caps, day limits) and financial requirements (copays, coinsurance) for mental health cannot be more restrictive than those applied to medical/surgical care in the same classification.

Catastrophic Plans

Catastrophic plans are a special category available only to people under 30 and to those who qualify for a hardship or affordability exemption. They cover the ten EHBs and free preventive care but have very high deductibles — equal to the ACA OOP maximum ($10,600 self-only in 2026). Catastrophic plans are not eligible for premium tax credits, and because their actuarial value is below 60%, they sit outside the metal tier system.

Actuarial Value vs. Out-of-Pocket Maximum

Actuarial value measures the plan's share of average covered costs (60/70/80/90%), while the OOP maximum is a hard dollar cap on the enrollee's in-network cost-sharing. A Bronze plan (60% AV) and a Platinum plan (90% AV) share the same $10,600 self-only / $21,200 family OOP maximum in 2026 — but the Bronze enrollee is far more likely to actually approach that cap because the plan pays a smaller share of each claim. Understanding both concepts is essential: AV describes expected cost-sharing, the OOP max caps worst-case exposure.

Large-Group and Self-Insured Plans

The EHB mandate applies to non-grandfathered individual and small-group plans. Large-group plans (generally 51+ employees, or 101+ in some states) and self-insured employer plans are not required to cover the full ten EHBs, although most do. However, the ACA's prohibition on annual and lifetime limits on EHBs does apply to all plans — including large-group and self-insured — for any EHB they do cover.