Essential Health Benefits: Gaps and Inconsistencies
April 12, 2023
What are Essential Health Benefits (EHBs)?
In the simplest of terms: Essential Health Benefits (EHBs) are the health care services that most health plans across the country must cover: services like pregnancy, maternity and newborn care; preventive and wellness care; emergency services; doctor visits; mental health and substance use disorder services, children’s vision and oral care, and more.
Essential Health Benefits (EHBs)
are the health care services that almost all insurance plans across the country are required to cover.
Despite the good intentions when this policy was developed 12 years ago, it has become clear that the benefits covered within insurance plans are not as comprehensive as intended.
The fight for health justice requires that we honestly assess what needs to change to make health a right for all — and to work towards that change every day. When it comes to minimum standards of coverage, or EHBs, making progress requires that we work to make EHB standards stronger so that the quality of health coverage improves for all people, whether they get health insurance through Marketplaces, their employer-sponsored plan, or programs like Medicaid.
Our health can’t wait.
Demand action from the Biden-Harris administration to Update our Essential Health Benefits
Here are some EHBs inequities and inconsistencies the Biden administration must address
The EHBs generally require coverage of Mental health and substance use disorder services, including behavioral health treatment. But EHB standards for mental health and SUD treatment services are so broad that patients’ access to life-saving SUD treatment medications like methadone, buprenorphine, and naltrexone depends on where they live and which health plan they choose. EHB coverage standards should clearly and consistently cover the full continuum of mental health and SUD treatment and services.
Our country’s maternal mortality crisis is only getting worse and disparities in maternal health outcomes for Black and Indigenous mothers are widening. Lack of clarity around EHB coverage for maternal health care at the federal level means that many patients encounter limits on prenatal and delivery services covered, inconsistent coverage of breastfeeding and lactation services, and unnecessary restrictions on midwives and doula services. This only compounds the racial inequities in access to high quality care for pregnant and postpartum people.
Transgender and nonbinary (TNB) individuals face significant marginalization in health care settings, including high rates of uninsurance, cost-related barriers to accessing needed care, and direct harassment and discrimination. Moreover, access to gender-affirming care is under direct attack at both the state and federal levels. While the Biden administration has taken steps to clarify protections against discrimination in health care based on sexual orientation and gender identity, EHB standards in many states are silent on coverage for gender-affirming care. Without greater clarity in federal EHB standards, access to this cost-effective and life-saving set of services remains at risk.
Oral health is essential to every person’s overall health and economic well-being. Access to dental care improves health outcomes for costly chronic conditions, reduces risk for adverse birth outcomes, and improves people’s job prospects. Yet, current EHB standards do not include dental coverage for adults, leaving millions of people to pay high out-of-pocket costs, seek care in emergency departments where they incur debt, or live in pain because they can’t afford the care they need. The Biden administration can close this glaring gap now by adding adult dental services to the EHBs.
Medicaid requires comprehensive and child-specific services in every state through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits, which are considered to be the gold standard. But private coverage differs because the EHBs do not currently define pediatric services beyond oral and vision care. This means that coverage for many children is based on insurance plans that were designed for adults. As many children are likely to transition to private coverage during the Medicaid unwinding, the Biden administration should make sure their access to care remains unchanged.
The price of prescription drugs is more than 2.5 times higher in the US than in other countries and those costs continue to outpace inflation. This leaves millions of people unable to pay for the medications they need. Coverage of prescription drugs varies in EHB plans from state to state and insurance plan documents aren’t always clear on what’s covered. At a minimum, the Biden administration should align EHB prescription drug coverage requirements with Medicare Part D, ensure coverage of all protected classes of drugs as well as medications opioid disorder treatment and reversal.
The law requires HHS to regularly review and update the EHBs but since the passage of the ACA in 2010, this has never happened. This means that coverage standards that apply to most private insurance plans haven’t kept pace with medical innovation or the needs of the 50 million or more people who have EHB coverage. The Biden administration should establish a permanent process to close gaps in EHB coverage and make timely updates but this can’t happen without the direct engagement of people who struggle to access the care they need. Any EHB review process or advisory body should ensure representation and participation of underserved and marginalized populations, including, but not limited to, Black, Hispanic and other people of color, people with disabilities, members of Tribal communities, and LGBTQ+ people, and other people with relevant lived experiences.
As more people come to count on EHB coverage standards, the Biden administration can build on its commitment to advancing health equity by improving benefits to ensure coverage allows everyone to get the care they want and need — without going into debt.
In July 2023, led by Community Catalyst, more than 50 groups launched a campaign urging the Biden administration to expand coverage of Essential Health Benefits (EHBs), which have not been updated since the Affordable Care Act (ACA) became law 13 years ago. The groups are calling on the Health and Human Services Secretary Xavier Becerra and Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure to close gaps and inconsistencies, and adopt several health care services into the EHB framework, including oral health care, expanding maternity and postpartum care, gender affirming care, and behavioral health and substance use disorder benefits. Doing so would advance equity amongst communities that disproportionately face barriers to care due to racism, classism and other forms of oppression.
Coverage alone is not enough. Despite record low insurance rates, there remains a key opportunity to make more services available to people under their insurance plans.
In a 2024 HIT Strategies poll commissioned by Community Catalyst, of those who say they are struggling to afford insurance and health care costs, over half (56%) report having delayed or foregone dental care services due to its cost, highlighting dental care as a problematic area when it comes to affordability.
Additionally, 83% of voters say they would support a proposal to enhance EHBs to encompass comprehensive health care needs, including dental coverage, a leading driver of medical debt, is paramount.
Related Resources
Essential Health Benefits 101
An introduction to Essential Health Benefits (EHBs), gaps and inconsistencies, and possible policy solutions.
Selecting a State EHB-Benchmark Plan Under New 2025 Regulations
In the Notice of Benefit and Payment Parameters (NBPP) for 2025, the annual rule that establishes standards for insurance plans sold on the ACA Individual and Small Group markets, CMS implemented important changes to the Essential Health Benefit (EHB) benchmark selection process. Under this rule, states are not only permitted to include routine non-pediatric dental services as Essential Health Benefits (EHBs) but have new flexibilities to expand coverage of benefits without having to take on additional costs. Learn more about these changes and how to support State advocates when engaging key decision-makers over the next three years.
Biden administration takes important step in addressing coverage gaps and inconsistencies in essential health benefits
Community Catalyst issues statement celebrating the Biden administration taking steps forward to address coverage gaps and inconsistencies in our essential health benefits by removing barriers to coverage for adult dental care.
Letter to the U.S. Department of Health and Human Services and Centers for Medicare & Medicaid Services
A coalition of organizations joined Community Catalyst to urge the Biden Administration to adhere to Essential Health Benefits (EHBs) to strengthen health care coverage.
Community Catalyst Calls on Biden Administration to Support Black Maternal Health By Setting a National Standard for Reproductive & Postpartum Care
Learn how Community Catalyst and its partners are working together to build community power to protect access to and shape equitable maternal health care policies.