Health benefits are regulated by both the federal government and individual state governments. The federal government requires that individual and small group plans cover certain Essential Health Benefits (EHBs).
Federal Essential Health Benefits (EHBs)
EHBs are broken down into 10 categories:
1. Ambulatory patient services
Ambulatory patient services refer to outpatient care you can get without being admitted to the hospital. Some services that fall under this EHB category include:
- Primary care visits to treat injury or illness
- Specialists, nurses, and physician assistant visits
- Allergy testing
- Home health care services
- Chemotherapy, radiation, and infusion therapy
- Hospice services
2. Emergency services
Emergency services include things like ambulance rides, urgent care centers or facilities, and emergency room services.
3. Hospitalization and surgery
This EHB category includes things like hospital and skilled nursing facility stays, inpatient physician and surgical services, transplants, and reconstructive surgery. Health plans may offer varying amounts of days of inpatient hospital/skilled nursing facility stays.
4. Maternity and newborn care
This EHB category includes things like prenatal and postnatal care, delivery, and all inpatient services for maternity care. Health plans may offer a varying amount of hospital stays after delivery.
5. Mental health and substance use disorder services
Mental health and substance use disorder services include inpatient and outpatient treatment. Health plans may offer a varying number of covered visits/stays.
6. Prescription drugs
This EHB category includes generic drugs, preferred brand drugs, non-preferred brand drugs, and specialty drugs.
7. Rehabilitative and habilitative services and devices
Rehabilitative and habilitative services and devices are used to help people with injuries, disabilities, or chronic conditions. Some things that fall under this EHB category include:
- Chiropractic care
- Hearing aids
- Prosthetic devices
- Durable medical equipment
- Rehabilitative speech therapy
- Outpatient rehabilitation services
- Rehabilitative occupational and rehabilitative physical therapy
Health plans may limit the number of visits per year or dollar amount paid for equipment.
8. Laboratory services
This EHB category includes lab work like x-rays and diagnostic imaging, CT/PET scans, MRIs, and other outpatient services.
9. Preventative and wellness services and chronic disease management
This EHB category includes things like:
- Preventative care screenings and immunizations
- Well baby visits and care
- Diabetes education and management and routine foot care
- Nutritional counseling
10. Pediatric services
Pediatric services refer to children’s health care services including routine eye exams, glasses, and dental care.
Besides the federal requirements listed above, Texas requires that health plans provide additional coverage benefits for consumers, often called mandates. Some of the state mandates do not apply to self-funded health plans, or others that are exempted from state law by ERISA.
Some examples of state mandates that provide additional insurance coverage for consumers include:
- Mastectomy and reconstructive surgery
- Maternity minimum stay (if maternity is covered)
- Chemical dependency treatment
- Cardiovascular disease screening tests
- HPV and cervical cancer screening
These mandates depend on a variety of factors; for example, whether a plan is an individual plan or a small group plan. For a comprehensive listing of federal and state mandates, and their applicability based on the type of plan, visit the Texas Department of Insurance (TDI)’s website.
Mandated health benefits can be confusing, especially when there is an overlap between both federal and state mandates. The easiest way to find out what your plan covers is to ask your health plan for your summary of benefits and coverage (SBC) document.
If you are concerned that your plan isn’t providing a mandated benefit, contact your health care provider. If that fails, you can file a complaint with TDI.