ACA Changes to Group Health Benefits' Essential Health Benefits
There are changes to individual benefits which I’ve talked about previously. More on that in the future. If you want to read the full announcement click here.
The below is from a service I subscribe to (MineralHR) which all of my groups have free access to (I pay for their subscriptions).
If you have questions, please reach out.
ACA: Changes to Essential Health Benefits
The U.S. Department of Health and Human Services (HHS) has issued a final rule with several changes that may impact employer-sponsored group health plans in 2026 and beyond.
While insurance carriers generally handle legal compliance for fully insured plans, employees may still have questions for their employer about changes to the plan. For self-insured and large group plans—even when using a third-party administrator (TPA)—employers are responsible for understanding the legal limits of plan design and their compliance obligations.
Notable Changes
Changes employers should be aware of include the following:
Sex-trait modification procedures: Plans subject to essential health benefit (EHB) requirements (generally small group fully insured plans) cannot classify certain sex-trait modification procedures (e.g., undergoing an operation to change a person’s biological sex) as EHBs. However, plans can still offer these services voluntarily, and states retain authority to mandate coverage, subject to Affordable Care Act (ACA) limits on state mandates.
Benchmark plan selection streamlined: Starting in 2026, states selecting new EHB benchmark plans must follow a single, consolidated pathway ensuring that plans reflect a typical employer plan and comply with ACA nondiscrimination rules. This may affect how EHBs are defined in fully insured small group coverage.
Stricter value limits: Revised actuarial value amounts in metal plans (i.e., tiered plans that might include bronze, silver, etc.) may require plan design adjustments to maintain compliance.
Routine adult dental services: For plan years starting in 2027, states can include routine non-pediatric dental services in their EHB-benchmark plans. If added by a state to their benchmark plan, fully insured plans in the small group market would be required to treat these as EHBs.
Applicability to Group Health Plans
Coverage requirements are as follows:
Small group fully insured plans must cover all state-defined EHBs.
Large group fully insured plans and self-funded plans are not required to cover all EHBs, but if they do cover any EHBs, they must comply with ACA mandates.
Action Items
Employers should work with their carriers or TPAs to assess how these changes impact their plan designs for the upcoming plan years.