Essential health benefits are the ten categories of care that marketplace and small group plans must cover: outpatient care, emergency services, hospitalisation, maternity and newborn care, mental health and substance use treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and chronic disease management, and pediatric services including dental and vision.
The point of the list is that it makes plans comparable. Two plans at different prices are covering the same categories, so the difference between them is cost sharing and network, not whether one of them quietly excludes maternity care.
That is also why the list matters when you encounter something that is not a marketplace plan. Short-term products, fixed-indemnity policies and health care sharing arrangements are not required to cover these categories, and the ones that look cheapest are usually the ones missing the most.
In New York: three consequences worth carrying around.
Maternity is covered by every marketplace plan, without exception. So the maternity question when comparing plans is never whether it is covered; it is what the deductible and out-of-pocket maximum are, because that is where the cost actually lands. What childbirth costs.
Mental health and substance use are on the list, and in New York they carry a further layer: cost sharing for outpatient mental health at a state-licensed facility may not exceed your primary care copay, and preauthorization is barred for outpatient addiction treatment at an OASAS-certified facility in your plan’s network. How parity works.
Pediatric dental and vision are included, while adult dental and vision generally are not and are sold separately. That asymmetry surprises people every year. Dental coverage in New York · Vision.
Note that “covered” is not the same as “free”. Only preventive care is required to be delivered without cost sharing. Everything else on the list is covered subject to your deductible, copays and coinsurance.
Also called: EHB, required benefits, covered categories. Full guide: How to compare plans in New York.
More in Glossary of health coverage and billing terms
- Metal tiers (bronze, silver, gold, platinum) — How marketplace plans are labeled by what share of costs the plan carries, not by quality of care.
- Navigator — A certified, free helper who walks you through enrollment and earns no commission on your choice.
- Sliding scale fee — A sliding scale fee is a price set by household income and size. How the scales at NYC community health centers and NYC Care work, and what to bring.
This page explains how the system works. It is not medical advice. More.