The Navigator Resource Guide has not been updated for 2025 Open Enrollment. For more current information please visit:
cms.gov/marketplace/in-person-assisters/information-partners.
QUESTION

I heard Marketplace plans have to cover certain health benefits referred to as essential. What are essential health benefits?

Individuals with no coverage | Comparing Plans: Benefits and Costs |
ANSWER

All qualified health plans offered in the Marketplace (as well as certain non-grandfathered individual plans sold outside the Marketplace) will cover essential health benefits. Categories of essential health benefits include:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care

The precise details of what is covered within these categories may vary somewhat from plan to plan. (45 C.F.R. § 147.150.)

Individuals with no coverage
Individuals with coverage
Coverage for small employers
Post enrollment issues