Essential Health Benefits in Texas

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Stacey Pogue /(512) 320-0222 x 117

July 23, 2012

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Starting in 2014, the Affordable Care Act (ACA) requires that health insurance plans for individuals and small businesses contain “essential health benefits” – a new floor for benefits that will help ensure people have comprehensive coverage. Essential Health Benefits (EHB) must also be included in the benefit package offered through the Medicaid expansion to adults up to 133 percent of the federal poverty level starting in 2014. The ACA outlines ten broad categories of essential health benefits (EHB) that include hospitalization, ambulatory care, maternity, mental health care, prescription drugs, and pediatric services.

It is up to each state to define the details of what services will be included and what service limits (an example of a service limit is 25 physical therapy visits per year) apply to the state’s EHB. States will do this by selecting an existing plan within the state to serve as a benchmark for the services and limits that will become the state’s EHB. States must select their EHB benchmark by September 2012.