Utah EHB Benchmark Requirement List.
The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care.
In addition to the basic EHB benefit categories, Utah has the following state-required benefits:
- Maternity Minimum Stay
- Catastrophic coverage of mental health conditions
- Coverage for prosthetic devices
- Coverage of Diabetes
- Mastectomy coverage
- Dietary products for inborn metabolic errors
- Autism Spectrum Disorder
Certain limitations and exclusions apply and may include the following examples:
- Ankle-foot orthotics
- Automated home blood pressure monitoring equipment
- Batteries (for any purpose)
- BiPAP and CPAP machines (including eligible attachments and supplies)
- Blood storage – autologous for future use
- Cane or quad cane
- Cardiac rehab; phases 3 and 4
- Chest compression vest, system generator, and hoses
- Circumcision
- Computer-assisted interpretation of x-rays (except mammograms)
- Computer-assisted navigation for orthopedic procedures
- Crutches
- Dynasplint
- Electrodes and accessories for stimulators
- Enuresis alarm unit
- Face Masks
- Fracture frame
- Freestanding/home cervical traction
- Glucometer (blood glucose monitor)
- Home anticoagulation or hemoglobin A1C testing
- Hospital beds and related parts or equipment
- Humidifiers
- Interferential/neuromuscular stimulators
- Lymphedema pump (pneumatic compressor), sleeves and supplies
- Magnetic Source Imaging (MSI)
- Manipulation under anesthesia
- Mastectomy bra
- Micro phlebectomy (stab phlebectomy)
- Pediatric/Infant scales
- Percussor, chest
- Postural drainage board
- Private Duty Nursing (PDN)
- Prosthesis, limb and supplies
- Protonic knee orthosis
- Radiofrequency ablation for lateral epicondylitis
- Scooter boards
- Sleep studies
- Speech generating device
- Stander
- Stereotactic radiosurgery
- Support hose (elastic stockings, surgical stockings)
- Tracheostomy speaking valve
- TENS unit
- Walkers and attachments
- Wheelchair -certain parts and accessories
Standard Utah Plans vs. Benchmark Plans
Utah offers three plan variations that satisfy the EHB mandate. Standard and Benchmark plans only cover EHBs, while Non-Benchmark plans cover EHBs as well as additional services. Standard and Benchmark plans may be a lower cost alternative to traditional Individual & Family (Affordable Care Act) plans. They only cover Essential Health Benefits as defined by your state.