15.1 ACA Essential Health Benefits and Metal Levels

The Patient Protection and Affordable Care Act (ACA), enacted in 2010, reshaped the individual and small-group health markets. Two of its most heavily tested mechanics are the Essential Health Benefits (EHBs) that every qualified plan must cover, and the metal levels that standardize how generously a plan pays. Together they answer the exam's favorite question: what does a compliant individual plan have to include, and how do you compare plans that all cover the same things?

The Ten Essential Health Benefit Categories

Every non-grandfathered individual and small-group plan must cover ten EHB categories. Plans cannot impose annual or lifetime dollar limits on these benefits.

Two traps inside the EHB list

Notice that maternity/newborn care is mandatory even on a plan sold to a single male; pre-ACA, maternity was a costly rider that most individual policies excluded. Pediatric dental and vision are EHBs, but adult dental and adult vision are not — a classic distractor.

Preventive services (immunizations, screenings, well-visits) must be provided with no cost-sharing when delivered in-network: $0 deductible, $0 copay, $0 coinsurance. Habilitative services (helping a person attain a skill, such as therapy for a child with a developmental delay) are listed alongside rehabilitative services (restoring a lost skill after illness or injury) — the exam may test the distinction between the two.

Grandfathered plans

A narrow exception exists for grandfathered plans — those continuously in force since March 23, 2010, that have not made significant benefit cuts or cost-sharing increases. Grandfathered plans are exempt from some EHB and cost-sharing rules but still cannot impose lifetime/annual dollar limits on essential benefits and must extend dependent coverage to age 26. Once a plan loses grandfathered status, it must comply fully.

Metal Levels and Actuarial Value

The ACA standardizes plan generosity using actuarial value (AV) — the percentage of total covered medical costs the plan is expected to pay for a standard population. The insured pays the rest through deductibles, copays, and coinsurance. The four metal levels:

A Catastrophic plan is a fifth option (roughly 60% AV) limited to enrollees under 30 or those with a hardship/affordability exemption. Catastrophic plans cover the three primary-care visits and preventive care, then little else until a high deductible is met, and they are not eligible for premium tax credits.

The inverse premium/cost-sharing relationship

The load-bearing concept: as AV rises, premium rises but out-of-pocket cost falls. Bronze has the cheapest monthly premium but you pay the most when you actually use care. Platinum costs the most each month but shields you at the point of service. Higher AV does not mean a different benefit set — all metal levels cover the same ten EHBs. They differ only in how the cost is split.

Worked AV example

Suppose a Silver plan (70% AV) faces $20,000 of covered claims for a standard enrollee population. The plan is expected to pay about $14,000 (70%), and enrollees collectively absorb roughly $6,000 (30%) through deductibles and coinsurance. AV is a population average, not a guarantee for one person — a healthy member may pay far less, a sick member far more, up to the out-of-pocket maximum.

Out-of-Pocket Maximum

Every EHB-covered plan must cap the insured's annual cost-sharing with an out-of-pocket (OOP) maximum. Once an in-network enrollee hits the cap, the plan pays 100% of further covered EHB costs for the year. For 2025 the federal limits are $9,200 for an individual and $18,400 for a family. The OOP max includes deductibles, copays, and coinsurance for in-network EHB care — but excludes premiums and out-of-network charges. Premiums are never part of the out-of-pocket maximum; that distinction is tested frequently.

How the cost-sharing pieces stack

The order of payment within a plan year matters on the exam. The insured first satisfies the deductible (the amount paid before the plan begins to share most costs). After the deductible, the insured pays coinsurance (a percentage of each covered charge) or fixed copayments (a flat dollar amount per visit or prescription) until reaching the OOP maximum. Preventive EHB services bypass this stack entirely — they are covered first-dollar with no deductible or copay in-network.

A worked illustration: a member with a $2,000 deductible and 20% coinsurance who incurs $10,000 of covered claims pays the $2,000 deductible plus 20% of the remaining $8,000 ($1,600), for $3,600 total — unless that figure would exceed the OOP max, in which case the plan absorbs the rest.