Qualified Health Plans (QHPs) and Essential Health Benefits (EHB)

Qualified Health Plans (QHPs) and Essential Health Benefits (EHB)

With the Health Insurance Marketplace (Exchange), individuals and small businesses may buy only high-quality, standardized qualified health plans that meet provider network standards. Standardization will allow easier comparison between different insurance plans. These plans are known as Qualified Health Plans (QHPs), and their coverage, at a minimum, should include Essential Health Benefits (EHB).

A plan is defined as qualified if it is satisfied the following requirements:

  • It must include a comprehensive package of benefits, known as  Essential Health Benefits (EHB).
  • It must adhere to limits on cost-sharing and out-of-pocket costs.
  • It must satisfy network adequacy standards.

Essential Health Benefits (EHB)

As of January 1, 2014, all non-grandfathered health plans in the individual and small group markets should cover a set of Essential Health Benefits. These include:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • 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

In addition, each plan must cover, at the very least, 60% of medical costs. In the terminology of Marketplaces, it is known as the Bronze plan.

Cost-Sharing and Out-of-Pocket Limits

All qualified health plans must limit cost sharing for enrolled individuals in the following ways:

  • Deductibles and copays cannot be applied to preventive services.
  • Non-grandfathered group health plans are prohibited from imposing a deductible greater than $2,000 for self only coverage, or $4,000 for coverage other than self-only.
  • Out-of-pocket costs for most health plans are capped at the health savings accounts (HSA) limit:
    • For the year 2016, the limits are $6,850 for an individual and $13,700 for a family.
    • For the year 2017, the limits are $7,150 for an individual and $14,300 for a family.
    • For the year 2018, the limits are $7,350 for an individual and $14,700 for a family.
    • For the year 2019, the limits are $7,900 for an individual and $15,800 for a family.

Network Adequacy in Qualified Health Plans

All qualified health plans must:

  • Offer a network with a sufficient number of providers, including mental health and substance abuse providers, to ensure access to all services without unreasonable delay, AND
  • Include a sufficient number of community providers to ensure reasonable and timely access to care for low-income populations.

Other Sources


Medicare Interactive

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