QHP Benefit Requirements: What Health Plans Must Cover in 2024

Table of Contents#

1. What is a Qualified Health Plan (QHP)?
2. Core Benefit Requirements: Essential Health Benefits (EHBs)
3. Additional Mandatory Coverages Beyond EHBs
4. Cost-Sharing Limits: Protecting Consumers from High Out-of-Pocket Costs
5. Special Populations and Additional Protections
6. How to Verify QHP Compliance
7. Conclusion
8. References

What is a Qualified Health Plan (QHP)?#

A Qualified Health Plan (QHP) is a health insurance plan that meets the ACA’s standards for coverage, affordability, and consumer protection. To be certified as a QHP, a plan must:

• Be sold on the Health Insurance Marketplace (either federal or state-based).
• Cover all Essential Health Benefits (EHBs).
• Adhere to cost-sharing limits (e.g., annual out-of-pocket maximums).
• Not discriminate based on pre-existing conditions, gender, or health status.
• Be eligible for premium tax credits and cost-sharing reductions (for low- and moderate-income enrollees).

QHPs can also be sold “off-exchange” (directly through insurers or brokers), but they must still meet these requirements to be considered “qualified.”

Core Benefit Requirements: Essential Health Benefits (EHBs)#

The ACA mandates that all QHPs cover 10 categories of Essential Health Benefits (EHBs). These benefits are designed to ensure comprehensive coverage for common medical needs, from preventive care to chronic disease management. While the categories are standardized, the specific services within each category may vary slightly by state, as EHBs are benchmarked to a state-specific plan (e.g., a state employee plan or the largest commercial HMO in the state).

Here’s a detailed breakdown of the 10 EHB categories:

1. Ambulatory Patient Services#

Covers outpatient care—services you receive without being admitted to a hospital. Examples include:

• Doctor’s office visits (primary care and specialists).
• Same-day surgery (e.g., minor procedures like cataract removal).
• Urgent care visits.
• Diagnostic tests (e.g., MRIs, CT scans) performed in an outpatient setting.

2. Emergency Services#

Requires coverage for emergency care, including:

• Trips to the emergency room (ER) for life-threatening conditions (e.g., heart attack, severe injury).
• No prior authorization for emergency services (you don’t need your insurer’s approval before seeking care).
• Protection against “balance billing” for out-of-network emergencies (thanks to the No Surprises Act, you can’t be charged more than in-network rates for emergency care).

3. Hospitalization#

Covers inpatient care, such as:

• Overnight hospital stays.
• Surgery performed during an inpatient stay.
• Maternity stays (see “Maternity and Newborn Care” below for more details).
• Intensive care unit (ICU) stays.

4. Maternity and Newborn Care#

Includes care before, during, and after childbirth:

• Prenatal visits (e.g., ultrasounds, blood tests).
• Labor and delivery (vaginal or cesarean).
• Postnatal care (for both mother and baby, including follow-up visits).

5. Mental Health and Substance Use Disorder Services#

Requires coverage for mental health care and treatment for substance abuse, with parity (equal coverage) to medical/surgical services. This includes:

• Counseling (individual, group, or family therapy).
• Psychiatric care (e.g., visits with a psychiatrist).
• Inpatient treatment for severe mental health conditions (e.g., bipolar disorder) or substance use disorders (e.g., opioid addiction).
• Prescription drugs for mental health (e.g., antidepressants, antipsychotics).

6. Prescription Drugs#

QHPs must cover at least one drug in each therapeutic category (e.g., antibiotics, blood pressure medications) and maintain a formulary (list of covered drugs). Plans may tier drugs (e.g., generic, brand-name, specialty) with different cost-sharing, but they cannot exclude entire categories.

7. Rehabilitative and Habilitative Services and Devices#

• Rehabilitative services: Help restore function lost due to injury, illness, or disability (e.g., physical therapy after a stroke, speech therapy after oral surgery).
• Habilitative services: Help develop function for those who never had it (e.g., occupational therapy for a child with autism, physical therapy for a child with cerebral palsy).
• Devices: Includes wheelchairs, hearing aids, braces, and other durable medical equipment (DME).

8. Laboratory Services#

Covers diagnostic tests used to detect, monitor, or treat health conditions, such as:

• Blood tests (e.g., cholesterol, blood sugar).
• Urinalysis.
• Genetic testing (when medically necessary).
• Imaging services (e.g., X-rays, mammograms) when ordered by a provider.

9. Preventive and Wellness Services and Chronic Disease Management#

QHPs must cover preventive services with no cost-sharing (i.e., no deductible, copay, or coinsurance). Examples include:

• Vaccinations (e.g., flu shot, HPV vaccine, shingles vaccine).
• Screenings (e.g., mammograms, colonoscopies, Pap smears, blood pressure checks).
• Counseling (e.g., smoking cessation, obesity counseling).
• Well-child visits (for children up to age 18).
• Chronic disease management (e.g., diabetes self-management training, asthma education).

10. Pediatric Services (Including Oral and Vision Care)#

Covers care for children under age 19, including:

• Well-child visits and immunizations.
• Pediatrician visits.
• Oral care: Dental checkups, cleanings, and fillings (note: adult dental care is not an EHB, though some QHPs may offer it as an optional benefit).
• Vision care: Eye exams and glasses (again, adult vision is not mandatory).

Additional Mandatory Coverages Beyond EHBs#

In addition to EHBs, QHPs must comply with other ACA requirements to protect consumers:

Coverage for Pre-Existing Conditions#

QHPs cannot deny coverage or charge higher premiums based on pre-existing conditions (e.g., diabetes, cancer, asthma). They also cannot impose waiting periods for coverage of pre-existing conditions.

No Annual or Lifetime Limits#

Plans cannot set annual or lifetime dollar limits on EHBs. For example, a plan can’t cap spending on chemotherapy at $100,000 per year.

Contraceptive Coverage#

Most QHPs must cover FDA-approved contraceptives (e.g., birth control pills, IUDs, implants) without cost-sharing, as part of preventive services. Religious employers may be exempt from this requirement under certain conditions.

Breastfeeding Support#

QHPs must cover breastfeeding services, including:

• Lactation consultant visits.
• Breast pumps (both rental and purchase, depending on medical need).

Mental Health Parity#

As noted earlier, coverage for mental health and substance use disorders must be no more restrictive than coverage for medical/surgical services. This means plans can’t impose higher copays or stricter prior authorization rules for mental health care.

Cost-Sharing Limits: Protecting Consumers from High Out-of-Pocket Costs#

QHPs must cap the amount enrollees pay out-of-pocket for covered services each year. This annual out-of-pocket (OOP) maximum includes deductibles, copays, and coinsurance—but not premiums, out-of-network services, or non-covered services.

For 2024, the OOP maximums are:

• Individuals: $9,450
• Families: $18,900

These limits are adjusted annually for inflation. Plans may set lower OOP maximums, but they cannot exceed these federal limits.

Special Populations and Additional Protections#

QHPs include safeguards for specific groups to ensure equitable access to care:

Young Adults#

QHPs must allow young adults to stay on their parents’ plan until age 26, regardless of whether they live at home, are married, or attend school.

Essential Community Providers (ECPs)#

QHPs must contract with enough ECPs—providers that serve low-income, rural, or underserved communities (e.g., community health centers, rural hospitals)—to ensure access for all enrollees.

Dependent Coverage for Children with Disabilities#

Even after age 26, some QHPs may extend coverage to dependents with disabilities if they are unable to support themselves.

How to Verify QHP Compliance#

When shopping for a health plan, use these steps to confirm it meets QHP requirements:

1. Check the Marketplace: Plans sold on HealthCare.gov or state Marketplaces are certified QHPs. Look for the “Qualified Health Plan” label.
2. Review the Summary of Benefits and Coverage (SBC): All QHPs must provide an SBC—a standardized, easy-to-read document that outlines covered benefits, cost-sharing, and examples of coverage (e.g., “What happens if I have a baby?”).
3. Verify EHB Coverage: The SBC will list which EHB categories are covered. If a category is missing, the plan is not a QHP.
4. Check Cost-Sharing Limits: Ensure the plan’s OOP maximum does not exceed the 2024 limits ($9,450 for individuals,$18,900 for families).
5. Contact the Insurer or State Insurance Department: If you’re unsure, ask the plan directly or check with your state’s insurance regulator for certification details.

Conclusion#

QHP benefit requirements are the backbone of the ACA’s promise to make health insurance comprehensive, affordable, and accessible. By mandating essential health benefits, capping out-of-pocket costs, and prohibiting discrimination, QHPs ensure that millions of Americans have access to the care they need.

Whether you’re enrolling in a Marketplace plan or reviewing an employer-sponsored option, understanding these requirements empowers you to choose a plan that protects your health and your wallet. Always verify compliance using the SBC and Marketplace tools, and don’t hesitate to ask questions—your health is worth it.

References#

• Centers for Medicare & Medicaid Services (CMS). (2023). Qualified Health Plans (QHPs). https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Qualified-Health-Plans
• U.S. Department of Health and Human Services (HHS). (2023). Essential Health Benefits. https://www.hhs.gov/healthcare/about-the-aca/essential-health-benefits/index.html
• CMS. (2023). 2024 Out-of-Pocket Maximum Limits. https://www.cms.gov/newsroom/press-releases/cms-announces-2024-health-insurance-marketplace-parameters
• No Surprises Act. (2021). Protecting Patients from Surprise Medical Bills. https://www.cms.gov/nosurprises