Are there regulations around EHB and MEC?

Yes, there are clear and distinct regulations around Essential Health Benefits (EHB) and Minimum Essential Coverage (MEC) under the ACA.

Here's how each is defined and regulated:

✅ Essential Health Benefits (EHB)

Definition:

The ACA mandates that all individual and small-group health insurance plans offered On-Exchange or Off-Exchange must include coverage for ten essential categories of health benefits.

10 Essential Health Benefit Categories:

1. Ambulatory patient services (outpatient care)

2. Emergency services

3. Hospitalization (inpatient care)

4. Maternity and newborn care

5. Mental health and substance use disorder services

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including dental and vision care

Regulatory requirements:

• Who Must Comply:
  All ACA-compliant individual and small-group plans (both on- and off-exchange).

• Who is Exempt:

  • Large-group employer plans (not strictly required, but typically comprehensive)

  • Grandfathered health plans (in existence prior to ACA enactment, provided no significant changes made)

  • Self-insured plans (ERISA regulated; exempt from exact EHB definitions, but most cover similar services)

✅ Minimum Essential Coverage (MEC)

Definition:

MEC is the minimum level of coverage required to meet ACA individual mandate obligations (now with $0 federal penalty), and for qualifying for certain enrollment rights or financial assistance.

Plans Generally Considered MEC:

• ACA-compliant individual and group insurance (On or Off-Exchange)

• Employer-sponsored group health plans (even minimal coverage or "skinny" plans)

• Medicare Part A / Medicare Advantage

• Medicaid and CHIP (comprehensive)

• TRICARE, VA coverage, and Peace Corps

Regulatory requirements:

• Who Must Comply:
  Individuals (previously enforced by federal penalty; currently $0 at federal level, but still applicable in some states like CA, MA, NJ, RI, DC, VT)

• Who is Exempt/Excluded:

  • Short-term limited-duration plans

  • Fixed indemnity insurance

  • Supplemental/critical illness policies

  • Health-sharing ministries

  • Limited Medicaid (family planning, emergency-only)

⚖️ Comparative Summary Table

Regulation TypeEssential Health Benefits (EHB)Minimum Essential Coverage (MEC)PurposeDefines specific benefits plans must coverDefines minimum coverage required by ACA mandateApplies toACA-compliant individual/small-group plansACA-compliant plans, Employer-sponsored plans, government plansExemptionsLarge-group plans, grandfathered/self-insured plansShort-term, limited-benefit, supplemental policiesRequired Benefits10 defined categoriesNo defined benefit categories (just minimal level of comprehensive coverage)EnforcementPlan certification by states/insurersPreviously IRS (now state-level where applicable)

🎯 Bottom Line:

• EHB specifically regulates the benefit structure (what plans must include).

• MEC regulates what coverage types qualify under the ACA individual mandate (a broader scope of acceptable plan types).

Understanding both ensures compliance and proper plan selection.