Study guide
4.4 ACA Essential Health Benefits
Accident & Health Insurance License Exam
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1 Introduction & Exam Overview
0.1 Current Exam Facts 0.2 Study Plan & Strategy
2 Chapter 1: Health Insurance Foundations
1.1 Insurance Principles and Contract Characteristics 1.2 Adverse Selection and the Underwriting Process 1.3 MIB and Consumer Reports 1.4 Policy Structure and Common A&H Provisions 1.5 The Twelve Mandatory Uniform Policy Provisions 1.6 Optional Uniform Provisions, Riders & Rights of Renewability
3 Chapter 2: Cost Sharing, Insurers, Distribution & Field Underwriting
2.1 Cost Sharing 2.2 Insurer Types, Admitted Status & Reinsurance 2.3 Marketing Systems, Agents & Brokers 2.4 Contract Law, Insurable Interest, Warranties & Representations 2.5 Field Underwriting: Application, Receipts, Delivery & Replacement 2.6 Ownership, Beneficiaries, Premium Modes & Cost Containment
4 Chapter 3: Medical Expense Plan Types
3.1 Basic and Major Medical Expense Plans 3.2 Health Maintenance Organizations (HMOs) 3.3 Preferred Provider Organizations (PPOs) 3.4 Point-of-Service (POS) and Exclusive Provider Organizations (EPOs) 3.5 Dental and Vision Plans 3.6 Limited, Supplemental & Worksite Health Policies
5 Chapter 4: Consumer-Directed Health & ACA Reforms
4.1 High-Deductible Health Plans & Health Savings Accounts 4.2 Flexible Spending Accounts & Health Reimbursement Arrangements 4.3 Coordination of Benefits 4.4 ACA Essential Health Benefits 4.5 ACA Market Reforms & Guaranteed Issue
6 Chapter 5: Disability Income Insurance
5.1 Disability Definitions 5.2 Elimination and Benefit Periods 5.3 Renewability, BOE, and SSDI 5.4 Disability Provisions and Exclusions 5.5 Group vs. Individual Disability and Taxation 5.6 Business Disability: Overhead Expense, Buy-Sell & Key Person
7 Chapter 6: Group Health, COBRA, HIPAA & ERISA
6.1 Group Health Underwriting 6.2 Contributory vs Noncontributory Plans 6.3 COBRA Continuation Coverage 6.4 HIPAA Portability & Privacy 6.5 ERISA & Employer-Sponsored Plans
8 Chapter 7: Medicare Parts A & B (Original Medicare)
7.1 Medicare Part A: Hospital Insurance 7.2 Medicare Part B: Medical Insurance
9 Chapter 8: Medicare Part C, Part D & Medigap
8.1 Medicare Advantage (Part C) 8.2 Medicare Part D (Prescription Drugs) 8.3 Medigap (Medicare Supplement Insurance)
10 Chapter 9: Medicare Enrollment, Medicaid & ACA Marketplace
9.1 Medicare Enrollment Periods 9.2 Medicaid 9.3 ACA Marketplace
11 Chapter 10: Long-Term Care Insurance
10.1 Tax-Qualified LTC & Levels of Care 10.2 ADL Triggers & Benefit Design 10.3 Inflation Protection & LTC Partnership Programs 10.4 LTC Provisions, Nonforfeiture & the NAIC Model Act
12 Chapter 11: Regulations & Ethics
11.1 Prohibited Trade & Claims Practices 11.2 Replacements, Parity, and Medicare Marketing 11.3 Producer Conduct, Premium Handling, and Ethics 11.4 Insurance Regulation, Solvency & Guaranty Associations
4.4 ACA Essential Health Benefits
Key Takeaways Explain This Topic AI
The ACA requires non-grandfathered individual and small-group plans to cover ten Essential Health Benefits (EHBs).
The 2026 ACA out-of-pocket maximum for in-network essential health benefits is $10,600 for self-only and $21,200 for family coverage.
ACA preventive care services must be covered with no cost-sharing when delivered in-network.
Metal tier actuarial values are Bronze 60%, Silver 70%, Gold 80%, and Platinum 90%.
Last updated: August 2026
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) :
- Ambulatory patient services (outpatient care)
- Emergency services
- Hospitalization (surgery, overnight stays)
- Maternity and newborn care
- Mental health and substance use disorder services (including behavioral health treatment)
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- 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:
- Metal Tier Actuarial Value
- Bronze 60%
- Silver 70%
- Gold 80%
- Platinum 90%
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.