Here's something that changed everything about health insurance: before the Affordable Care Act passed in 2010, your health plan could simply choose not to cover maternity care. Or mental health services. Or prescription drugs. Insurers cherry-picked what they'd pay for, leaving people with surprise gaps in coverage exactly when they needed help most.
That's why essential health benefits matter so much. Since 2014, every ACA-compliant health plan—whether you buy it on the marketplace or directly from an insurer—must cover 10 core categories of care. This means you're guaranteed comprehensive coverage that actually protects you when life throws curveballs your way. Let's break down exactly what you're entitled to and how to make the most of these benefits.
The 10 Essential Health Benefits You're Guaranteed
Think of essential health benefits as your healthcare safety net. Every plan sold in the individual and small group markets must cover these 10 categories with no annual or lifetime dollar limits:
Ambulatory patient services are your everyday outpatient care—doctor visits, specialist appointments, and outpatient surgery. This is the coverage you'll use most often for routine health concerns and follow-up care.
Emergency services must be covered without requiring prior authorization, even if you go to an out-of-network hospital. If you're having a medical emergency, you shouldn't have to worry about whether the ambulance is taking you to the "right" hospital.
Hospitalization covers inpatient stays, including surgery, room and board, and care during your hospital stay. Whether you're having planned surgery or an unexpected health crisis, this benefit protects you from catastrophic bills.
Maternity and newborn care includes prenatal visits, labor and delivery, and postpartum care for both mother and baby. This was a game-changer—before the ACA, pregnancy could be treated as a pre-existing condition or excluded entirely from coverage.
Mental health and substance use disorder services receive equal treatment to physical health services. This means coverage for therapy, counseling, inpatient psychiatric care, and addiction treatment—services that were often severely limited or excluded before 2014.
Prescription drugs must be covered, though plans maintain formularies that determine which specific medications are covered and at what cost-sharing level. Your plan must cover at least one drug in each category and class.
Rehabilitative and habilitative services help you recover abilities after illness or injury (rehab) or develop skills you never had (habilitation). This includes physical therapy, occupational therapy, and speech therapy, plus necessary devices and equipment.
Laboratory services cover the diagnostic tests your doctor orders, from routine bloodwork to more complex testing that helps diagnose or monitor health conditions.
Preventive and wellness services are where your plan really shines. These services—including cancer screenings, vaccinations, annual checkups, and chronic disease management—must be covered at 100% with no copay or deductible when you use in-network providers.
Pediatric services include dental and vision care for children, addressing one of the biggest gaps in pre-ACA coverage. Kids' dental cleanings, vision exams, and glasses are built into every plan.
Why State Variations Matter for Your Coverage
Here's where it gets interesting: while every state must cover the same 10 categories, the specific services within each category can vary based on your state's benchmark plan. Think of the 10 categories as the foundation that's identical everywhere, but each state gets to customize the details of what's built on that foundation.
For example, Vermont updated its benchmark plan for 2024 to cover prescription hearing aids (one set every three years) and expanded access to nutritional counseling and rehabilitative services. Other states like North Dakota and Virginia also made changes to their benchmark plans for 2025. These updates mean that if you live in one of these states, you have access to enhanced benefits beyond the baseline requirements.
This state-by-state flexibility is intentional. It allows states to address the specific health needs of their populations while maintaining the federal guarantee of comprehensive coverage. Since 2019, states have had even more flexibility to update their benchmark plans, and many have taken advantage of this to fill coverage gaps and add valuable services.
Getting the Most Value from Free Preventive Care
One of the most underutilized benefits in health insurance is preventive care. Your plan must cover preventive services at no cost to you—no copay, no coinsurance, no deductible—when you use an in-network provider. This includes screenings, vaccinations, and counseling services recommended by the U.S. Preventive Services Task Force, the CDC, and the Health Resources and Services Administration.
We're talking about valuable services like mammograms, colonoscopies, blood pressure screenings, diabetes screening, depression screening, obesity counseling, tobacco cessation support, and contraception. For women, this includes well-woman visits, breastfeeding counseling, and domestic violence screening. For kids, it covers a comprehensive set of pediatric preventive services from birth through age 21.
The catch? You must see an in-network provider and the service must be preventive, not diagnostic. If your doctor finds something during a preventive screening and orders additional tests, those follow-up services may be subject to your regular cost-sharing. But the initial preventive visit and screening are always free.
What This Means When Choosing a Health Plan
Essential health benefits level the playing field across all marketplace plans. Whether you're looking at a bronze plan with lower premiums and higher deductibles or a platinum plan with higher premiums and lower out-of-pocket costs, you're getting the same core coverage. The difference is in how much you pay when you use that coverage, not whether the service is covered at all.
This changes the comparison shopping game. Instead of trying to decode which plan covers what services, you can focus on the factors that really matter: the size of the provider network, your total expected costs based on your health needs, whether your current doctors are in-network, and the prescription drug formulary if you take regular medications.
For people with specific health needs, essential health benefits provide peace of mind. If you're planning to have a baby, managing a mental health condition, or dealing with a chronic illness requiring regular prescriptions, you know every plan on the marketplace will cover these needs. Your job is simply to find the plan that covers them most affordably for your situation.
How to Use Your Essential Health Benefits
Start by reviewing your plan's Summary of Benefits and Coverage—a standardized document that shows exactly how your plan covers each essential health benefit category. This tells you what you'll pay for common services, from a primary care visit to a hospital stay to prescription drugs.
Schedule those free preventive care visits. If you haven't had your annual wellness checkup, age-appropriate cancer screenings, or recommended vaccinations, you're leaving money on the table. These services catch health problems early when they're most treatable and least expensive to manage.
If you need mental health care, don't hesitate to use it. Mental health parity laws mean your plan must treat mental health services the same as physical health services—same copays, same coverage limits, same access. If you're struggling with anxiety, depression, or substance use issues, these services are there for you without discrimination or excessive barriers.
Essential health benefits represent a fundamental shift in how health insurance works in America. Instead of wondering whether your plan covers the care you need, you can trust that every ACA-compliant plan provides comprehensive protection across all major categories of healthcare. The question isn't whether you're covered—it's how to make smart choices about which plan delivers that coverage most cost-effectively for your unique health needs and budget. Ready to explore your options? Compare marketplace plans during open enrollment or after a qualifying life event to find coverage that works for you.
