Key takeaways:
Essential health benefits are the medical services that must be covered under any Affordable Care Act (ACA) marketplace plan.
The 10 essential health benefits include preventive care, emergency services, prescription medications, and mental health services.
ACA plans also must offer dental coverage for children, and they may provide additional benefits.
The Affordable Care Act (ACA), a 2010 comprehensive health-reform law commonly known as Obamacare, has three main goals:
Make affordable health insurance available to more people
Expand the Medicaid program
Support innovation in medical care delivery that reduces costs
The first plans to provide health coverage were effective in 2014. Now, ACA health plans are sold through HealthCare.gov and state marketplaces. All ACA health plans must include coverage for 10 essential health benefits. They also need to offer dental coverage for children. You aren't required, however, to purchase dental coverage.
What are the ACA’s 10 essential health benefits?
There are 10 essential health benefits that all ACA plans must cover:
Emergency services
Hospitalization (for surgeries and inpatient care)
Laboratory services
Mental health and substance use disorder services (including behavioral health treatment such as counseling and psychotherapy)
Outpatient care
Pediatric services (including oral and vision care)
Pregnancy, maternity, and newborn services (including prenatal, childbirth, and postnatal care)
Prescription medications
Preventive care, wellness services, and chronic disease management
Rehabilitative and habilitative services and devices to help people with an injury, disability, or chronic condition gain or recover skills
What preventive health services fall under essential health benefits?
One category of essential health benefits that applies to almost everyone is preventive care. If you have an ACA plan, you can access preventive health services, such as vaccinations and screenings, without paying out-of-pocket costs. That means you do not pay toward your deductible and are not charged a copay or coinsurance when you receive routine preventive care from a healthcare professional in your plan’s network.
Preventive care benefits vary for children, adults, and women, specifically. For instance, there are more than 2 dozen preventive care benefits for children, including:
Autism screening at 18 months and 2 years old
Fluoride varnish
Hearing screening for newborns
Lead screening for children at risk of exposure
Obesity screening and counseling
Routine depression screening beginning at age 12
Vision screening
Well-baby and well-child visits
There are more than 20 preventive care benefits for adults, including:
Colorectal (colon) cancer screening for adults ages 45 to 75
Lung cancer screening for adults age 50 to 80 who are high risk (heavy smokers and those who quit in the past 15 years)
One-time abdominal aortic aneurysm screening for men of certain ages who have smoked
Statin-preventive medication for adults ages 40 to 75 at high risk of heart attack or stroke
There are another 27 preventive care benefits specifically for women, including:
Birth control services, such as contraceptives, sterilization, and counseling
Bone-density screening for women ages 65 and older (and those 64 and younger who have gone through menopause)
Breast cancer genetic test counseling (BRCA) for women at higher risk because of family history
Folic acid supplements for women who may become pregnant
Maternal depression screening for mothers at well-baby visits
Screening mammogram for breast cancer
Well-woman visits
How much do you pay out of pocket for essential health benefits?
ACA health insurance plans have a monthly premium and other out-of-pocket costs related to care. Individuals and families within certain income limits — those earning 100% to 400% of the federal poverty level — will qualify for the premium tax credit.
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Beyond your monthly premium, you will likely have to pay out-of-pocket costs when you receive care that isn’t considered preventive. You may also be charged if you receive preventive care from an out-of-network healthcare professional.
These are the types of out-of-pocket costs you are responsible for with an ACA plan:
Deductible: This is what you will spend before your plan will pay for services other than preventive health services. This includes specific in-network care, such as checkups and screenings, without paying toward your deductible or anything else out of pocket.
Copayments and coinsurance: After you meet your deductible, you may be charged a copayment or coinsurance when you access care. A copayment, or copay, is a fixed amount you pay for a service. Coinsurance is a percentage of the cost of a covered health service that you’re responsible for.
Out-of-pocket maximum: Also known as the out-of-pocket limit, this is the maximum amount you pay for covered services in a plan year. If your deductible, copayments, and coinsurance reach this amount, your plan pays 100% of the costs of covered services for the rest of the year. In 2026, the out-of-pocket maximum is $10,600 for an individual and $21,200 for a family.
Starting in 2021, enhanced premium tax credits significantly lowered premiums and expanded the population eligible for savings. In 2025, that meant 90% of ACA enrollees — about 20 million people — received additional savings on the cost of plans. These enhanced subsidies were eliminated for the 2026 coverage year. As a result, many people now have higher premiums.
What is not covered under the ACA’s essential health benefits?
Essential health benefits do not include certain services, such as:
Dental care for adults, though some plans may offer this benefit
Vision care for adults, though some plans may offer this benefit
Do large employers have to cover essential health benefits?
Applicable large employers must offer affordable health insurance with minimum essential coverage to their employees (and their employees’ dependents). Under the IRS definition, an applicable large employer had at least 50 full-time employees (including full-time equivalent employees) on average during the previous year.
If the health insurance offered is not considered affordable, the employer may have to pay a fine to the IRS. This employer shared responsibility is sometimes called the ACA employer mandate.
How does the coverage provided for essential health benefits change from plan to plan?
As mentioned, all ACA plans must offer coverage for the 10 essential health benefits. This is true for all metal tiers (platinum, gold, silver, and bronze) as well as all plan types, including preferred provider organization (PPO) and health maintenance organization (HMO) plans.
Coverage for essential health benefits is also included in catastrophic health plans, which are for people who want financial protection in the case of serious illness or injury. These plans also cover preventive health services before the deductible is met. Catastrophic plan premiums are very low, but the deductibles are very high. In 2026, ACA catastrophic health plans have an annual deductible of $10,600 for individuals and $21,200 for families for covered services.
Between states — and sometimes within states — there can be slight differences in the essential health benefits covered by plans. Carefully check the coverage details for any ACA plan you are considering to make the best choice for you and your family.
Frequently asked questions
Open enrollment for ACA plans happens late in the previous year for coverage beginning January 1. Starting in the fall of 2026 for the 2027 coverage year, open enrollment will become more uniform nationwide. Regardless of where you live and whether you use HealthCare.gov or a state marketplace, the open enrollment period must:
Begin no later than November 1
End by December 31
Last no longer than 9 weeks
You may be eligible to enroll in a catastrophic health plan if you qualify for a hardship exemption, such as for having trouble affording marketplace premiums or losing your job-based health insurance. Catastrophic plans are also available to people under age 30 for any reason.
You may also qualify for Medicaid. Your ACA marketplace application can help you determine if you qualify for the program in your state or territory.
If you’re younger than 26 or in college, you may be eligible to remain on a parent’s health insurance plan or qualify for student or campus health insurance.
Premium subsidies are monthly discounts in the form of premium tax credits that reduce the cost of your ACA health insurance plan. These subsidies are based on your estimated income in a coverage year. But you may end up with a higher tax bill If your actual income is more than the estimate.
Open enrollment for ACA plans happens late in the previous year for coverage beginning January 1. Starting in the fall of 2026 for the 2027 coverage year, open enrollment will become more uniform nationwide. Regardless of where you live and whether you use HealthCare.gov or a state marketplace, the open enrollment period must:
Begin no later than November 1
End by December 31
Last no longer than 9 weeks
You may be eligible to enroll in a catastrophic health plan if you qualify for a hardship exemption, such as for having trouble affording marketplace premiums or losing your job-based health insurance. Catastrophic plans are also available to people under age 30 for any reason.
You may also qualify for Medicaid. Your ACA marketplace application can help you determine if you qualify for the program in your state or territory.
If you’re younger than 26 or in college, you may be eligible to remain on a parent’s health insurance plan or qualify for student or campus health insurance.
Premium subsidies are monthly discounts in the form of premium tax credits that reduce the cost of your ACA health insurance plan. These subsidies are based on your estimated income in a coverage year. But you may end up with a higher tax bill If your actual income is more than the estimate.
The bottom line
Affordable Care Act (ACA) plans provide coverage for 10 essential health benefits. This minimum standard ensures enrollees have access to coverage for critical healthcare needs. Specific essential health benefits covered by each plan can vary, so be sure to review offerings carefully before you enroll.
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References
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Internal Revenue Service. (2024). Determining if an employer is an applicable large employer.
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KFF. (n.d.). What is a catastrophic health plan?
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