Essential Health Benefits (EHBs) are the benefit categories that individual and small group policies must cover:
Ambulatory (outpatient) services
Maternity and newborn care
Mental health and substance use disorder services
Rehabilitative and habilitative services and devices
Preventive and wellness services
Pediatric services, including oral and vision care
Exam traps: dental and vision appear only under pediatric services, so routine adult dental is not an EHB category. The requirement applies to individual and small group policies, inside or outside the Exchange (§10112.27). Grandfathered plans and excepted benefits are carved out, and large group policies are not named in the requirement.
Metal tiers describe how the plan and enrollee share costs (the plan's actuarial value), not the quality of care. Every tier covers the same essential health benefits.
- Bronze: 60% (enrollee pays about 40% on average)
- Silver: 70%
- Gold: 80%
- Platinum: 90% (enrollee pays about 10% on average)
A higher tier means the plan pays more when you get care, generally in exchange for a higher premium.
Allowed variation: in California, a tier's actuarial value may not vary by more than plus or minus 2 percent (§10112.295(b)(1)), so a "Silver" plan at 67% fails. The federal rule is looser at minus 4 percentage points, but the California statute governs a California policy.