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Most individuals are required to be covered by and employers with 50 or more full-time
employees are required to offer minimum essential coverage or face a penalty. Minimum
essential coverage is a broad definition that includes major medical health coverage under the
following:
1. A government-sponsored program
2. An eligible employer-sponsored plan
3. A health plan offered in the individual market
4. A grandfathered health plan
5. Other health benefits coverage as HHS recognizes
Most employer-provided group coverage will qualify as “minimum essential coverage”. Any
“eligible employer-sponsored plan” means a group health plan that is either a government a
plan offered in a state’s small or large group market. Self-insured employer coverage qualifies.
Additionally, benefits offered to a former employee such as COBRA or retiree health coverage
qualifies. It does not, however, include certain HIPAA excepted benefits, and is separate and
distinct from the Essential Health Benefits.
These benefits are required to include at least the following 10 broad categories:
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance abuse 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
Applies to: Insurance carriers offering insurance coverage to small businesses, and optional
for self-insured and large businesses. Does not apply to grandfathered plans.
Health plans will be required to offer health insurance that meets certain levels of coverage.
The coverage levels are based upon the actuarial value of the plan and are represented by
metal levels: Bronze, Silver, Gold or Platinum. These values indicate the percentage of total
average costs for covered benefits that a plan will cover. For example, if a plan has a “Silver”
Essential Health
Benefits (EHB)
Minimal Essential
Coverage
Actuarial Value
Standards
(Metal Levels)
