Essential Health Benefits (EHB) protections are one of the central pillars of the Affordable Care Act (ACA). They ensure that coverage that was made more affordable under the law is also comprehensive. EHB requirements enjoy broad public support and have improved access to a comprehensive standard for benefits in certain health insurance plans.
Recent communications from the Centers for Medicare and Medicaid Services (CMS) indicate that federal rules implementing EHB protections may be in for a major overhaul. This post provides a refresher on EHB protections and how they have been implemented to date before summarizing key questions that could inform future rulemaking.
What are Essential Health Benefits?
Prior to the ACA, health insurance available to individuals buying coverage on their own and to small businesses often had large gaps in coverage, including limited or no benefits for maternity care, mental health and substance use disorder services, and prescription drugs. For example, 75% of individual market plans failed to cover maternity care, and 45% did not cover substance use disorder services. Congress established EHB to close these gaps and facilitate access to services that were often excluded from coverage.
EHB protections require that, starting in 2014, plans sold in the individual and small-employer markets cover a comprehensive set of benefits that better reflect those typically included in the employer-sponsored insurance (ESI) most people rely on. Key EHB statutory requirements include:
- Ten categories of required coverage. Coverage must include at least ambulatory (outpatient) services, emergency care, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive care, and pediatric care.
- Scope equal to typical employer plan. The Secretary of Health and Human Services (HHS) must ensure that the scope of EHB “is equal to the scope of benefits provided under a typical employer plan.”
- Cost-sharing protections. To help ensure consumers can afford to access essential services, the ACA places a cap on annual out-of-pocket costs for EHB and prohibits annual or lifetime dollar-value limits on EHB (these specific protections extend to most commercial health plans, including employer-sponsored insurance).
- Meet diverse needs, without discrimination. The HHS Secretary should ensure that the EHB package is balanced across the 10 categories; takes into account health care needs of diverse segments of the population; and does not discriminate based on age, disability, or expected length of life.
- Periodic updates. The HHS Secretary must periodically review EHBs and update them to address barriers faced by consumers seeking services and to keep pace with medical evidence and scientific advances.
How have EHB been implemented?
The ACA does not list specific items and services that must be covered within the ten EHB categories and instead directs the HHS Secretary to ensure the scope of coverage is equal to a “typical employer plan.” HHS implemented this framework by creating a state EHB “benchmark” process. Through it, states designate an existing plan or set of benefits, subject to federal guardrails, as the state’s EHB benchmark plans, and all plans sold in the state’s individual and small employer markets must cover items and services in a manner “substantially equal” to the benchmark. HHS has modified the process for a state to select or update its EHB benchmark plan a few times through rule, but has maintained the states’ leading role and the benchmark plan framework.
All states selected EHB benchmark plans for 2014 and 2017. Most states are still using the benchmark plan they selected for 2017, though 11 states and D.C. have received federal approval under the Trump or Biden administrations to update their EHB benchmark plan. Action in these states has been motivated by a desire to further state policy goals and/or update an EHB benchmark plan viewed as out-of-date. For example, six states (Colorado, Illinois, Michigan, New Mexico, North Dakota, and Oregon) expanded coverage of medications that treat opioid use disorder or reverse overdoses, and two states (New Mexico and North Dakota) expanded access to GLP-1 medications.
Additional states, which appear to include California, Kentucky, Nevada, Utah, and West Virginia, submitted benchmark update proposals to CMS in May 2025 with a planned effective date of January 2027; however, in 2026, CMS announced it was “pausing review” of state EHB benchmark updates while it reviews and possibly revises EHB-related rules.
EHB Request for Information and Future Rulemaking
In June 2026, CMS released a request for information (RFI) soliciting input on the EHB framework “in light of significant changes…in employer-sponsored insurance coverage, advances in health care innovations and delivery, shifts in the utilization of services, and rising health care costs.” CMS explains that these changes necessitate a “renewed examination” of the approaches to determine the scope of EHB and whether benefits are typical of ESI, signaling likely areas for future agency rulemaking.
The RFI requests feedback on a broad scope of EHB-related topics including:
- The framework for identifying a “typical employer plan” and determining the scope of EHB;
- Variation across states’ EHB benchmark plans;
- How the scope of EHB affects affordability and costs;
- Periodic review of EHB to identify gaps and keep pace with medical evidence; and
- The process for updating state EHB benchmark plans.
The RFI’s 30-day comment deadline closed on July 15, 2026. The agency received 179 responses, including many from members of the public, patient and consumer organizations, health care provider associations, and insurer and other industry stakeholders.
What additional information is needed?
While commenters undoubtedly supplied useful context, several noted the 30-day timeline was inadequate to provide a full response to CMS’s broad and complex questions. Comments from the National Association of Insurance Commissioners, for example, noted that state regulators do not have ready access to detailed data needed to respond to some questions and strongly encouraged CMS to engage actuarial expertise before moving forward. CMS will need to gather additional information, some of which does not readily exist today, to answer the questions it posed and inform its next steps, including in the areas discussed below.
Scope of coverage in typical ESI. While information on the scope of coverage for items and services in fully insured and public employee plans is more readily accessible through form filings and other information, similar information is not publicly available from self-insured employer plans that cover most workers. During initial EHB implementation, the Department of Labor (DOL) surveyed ESI plan documents to better understand how benefits were typically covered. But this survey was far from comprehensive. The agency was often working from coverage summaries or comparison tables with minimal detail, and the resulting 2011 report generally identifies whether a specific service is mentioned rather than the actual scope of coverage. For example, the DOL report indicates that 67% of workers had plan documents that mentioned coverage of durable medical equipment (DME), while 33% had plans in which DME is not mentioned. This does not, however, mean that DME wasn’t covered for those 33% of workers. A Mercer survey from the same period found that 97% of employers cover DME to some degree. The RFI raises questions about the intersection of self-insured plans and “typical” employer coverage. If CMS wants to understand the breadth of self-funded coverage and what is typical, as opposed to cherry-picking examples of skimpy self-funded plans, which comments from the National Health Law Program cautioned against, it will likely require new research and analysis.
Periodic review and update. EHB provisions have been in effect for more than 12 years, and during that time, HHS has not undertaken its statutory obligation to periodically review EHB and update as needed to: 1) address difficulties consumers face accessing needed services due to gaps in coverage or cost, or 2) reflect changes in medical evidence or scientific advances. If CMS conducts this arguably overdue review now, it could inform future rules and shed light on what changes within the EHB framework could help it better adapt to changes in medical evidence.
Costs and affordability. The RFI focuses on premium costs more than other aspects of affordability for consumers and links EHB coverage to premium increases. This overlooks market-wide drivers of high health care costs that affect the entire commercial insurance market, not just plans subject to EHB. It also does not acknowledge evidence that recent federal ACA policy changes are contributing to Marketplace premium increases.
While there are tradeoffs between the scope of coverage and premium costs, premiums are just one aspect of affordability for consumers. When covered, a benefit is subject to cost sharing (minus any cost-sharing reductions for eligible Marketplace enrollees), but may otherwise be prohibitively expensive if not covered. In addition, benefits covered as EHB are subject to other affordability protections, including no annual or lifetime dollar limits and an annual cap on out-of-pocket spending. Health care affordability is a top concern for Americans. To meaningfully evaluate it, CMS would need to consider affordability for consumers more holistically, including evaluating the impacts on consumers when high-cost but necessary services are not covered as EHB.
Looking Ahead
EHB protections make essential health care services more accessible and affordable for consumers with individual market and small employer coverage who, before the ACA, had long faced gaps in coverage. CMS’s RFI suggests a major overhaul to the EHB framework may be coming and acknowledges that the agency needs more information to shape changes. Ultimately, CMS may need to conduct additional research and/or analysis in several areas to answer the questions it posed.
