Essential health benefits: what every ACA plan covers
The ten categories of care every Colorado ACA plan must cover, what Colorado adds through its own benchmark plan, the 2026 and 2027 out-of-pocket limits, and a worked maternity example on the 2027 Colorado Option plans.
Every individual and small-group health plan sold under the Affordable Care Act, on or off the Colorado marketplace, must cover ten categories of essential health benefits: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use services, prescription drugs, rehabilitative and habilitative services, lab work, preventive and wellness care with chronic disease management, and pediatric care including children's dental and vision (CMS, 2026). Plans cannot put a yearly or lifetime dollar cap on these benefits, and what you pay for covered in-network care is capped each year: no more than $10,600 for one person in 2026 and $12,000 in 2027 (CMS payment parameters guidance, January 29, 2026, cms.gov/files/document/2027-papi-parameters-guidance-2026-01-29.pdf). Colorado then fills in the details through its own benchmark plan, which is why a Colorado plan covers things a plan in another state may not. This guide explains the federal floor, what Colorado adds on top, and how the yearly cap plays out in a real 2027 plan design.
The ten categories, in plain English
Federal law names ten categories, and every individual and small-group ACA plan has to include all of them. The list is the same on every plan sold through the Colorado marketplace, and on ACA plans bought directly from an insurer. What changes from plan to plan is the detail inside each category: which drugs are on the list, which doctors and hospitals are in the network, and what you pay when you use the benefit.
Children's dental and vision care are part of the pediatric category. Adult dental and adult vision are not essential health benefits, and the federal marketplace notes that only some plans include vision coverage for adults (CMS, 2026).
| Category | What it means for you |
|---|---|
| Ambulatory patient services | Doctor visits and outpatient care when you are not admitted to a hospital |
| Emergency services | Emergency room care |
| Hospitalization | Inpatient stays, including surgery and overnight stays |
| Pregnancy, maternity and newborn care | Care before, during and after birth |
| Mental health and substance use disorder services | Psychotherapy, talk therapy and behavioral health treatment |
| Prescription drugs | Drugs on the plan's list (formulary), which varies by plan |
| Rehabilitative and habilitative services and devices | Therapy and devices to regain skills after an injury, or to build skills for a disability or chronic condition |
| Laboratory services | Blood work and other tests |
| Preventive and wellness services and chronic disease management | Screenings, vaccines and ongoing care for conditions like diabetes |
| Pediatric services, including oral and vision care | Children's care, with dental and vision for kids |
No annual or lifetime dollar limits
Before the ACA, a serious illness could use up a policy's lifetime maximum and leave a family uninsured for the rest of the treatment. Today an insurer cannot set a lifetime dollar limit on what it spends on essential health benefits, and it cannot set a yearly dollar limit on what it spends on your coverage (CMS, 2026). Two exceptions are worth knowing. Insurers can still put dollar limits on services that are not essential health benefits, and the protection against yearly limits does not apply to grandfathered individual plans, which are rare.
Some plans still limit the number of visits for certain services, such as therapy visits, as long as the limit follows state and federal rules. A visit limit is different from a dollar limit, so check the plan documents for any service you expect to use often.
The out-of-pocket maximum: the number that protects you in a bad year
Every ACA plan has an out-of-pocket maximum. Once your deductible, copays and coinsurance for covered in-network care reach that amount in a plan year, the plan pays 100% of covered in-network care for the rest of the year. Federal rules set a ceiling on how high a plan's maximum can be. CMS set it at $10,600 for self-only coverage and $21,200 for other than self-only coverage in 2026, and at $12,000 and $24,000 for 2027, an increase of about 13.2% (CMS payment parameters guidance, January 29, 2026, cms.gov/files/document/2027-papi-parameters-guidance-2026-01-29.pdf). The federal marketplace lists the same limits (CMS, 2026).
The cap has limits of its own. Your monthly premium does not count toward it, and neither does spending on services the plan does not cover, care from out-of-network providers, or charges above the amount a provider is allowed to bill (CMS, 2026). That is why staying in network matters as much as the size of the cap. Many plans set their own maximum below the federal ceiling, and the Colorado Option plans described below are examples.
| Plan year | Self-only | Other than self-only (family) |
|---|---|---|
| 2026 | $10,600 | $21,200 |
| 2027 | $12,000 | $24,000 |
How Colorado decides the details: the benchmark plan
Federal law names the categories, and each state chooses a benchmark plan that sets the specific services inside them. The Colorado Division of Insurance (DOI) maintains Colorado's benchmark, which sets the minimum essential health benefits for individual and small-group ACA plans in the state (Colorado DOI, 2026, doi.colorado.gov/types-of-insurance/health-insurance/aca-information/aca-ehb-benchmark-health-insurance-plan). Colorado's rule defining essential health benefits is Colorado Insurance Regulation 4-2-42.
Colorado's benchmark has changed three times. From 2017 through 2022 it was based on a Kaiser HMO plan the state selected in 2015. For 2023 through 2026, the DOI worked with stakeholders and an actuarial firm in 2021 to add new benefits, and CMS approved the plan on October 12, 2021 (Colorado DOI, October 12, 2021, doi.colorado.gov/news-releases-consumer-advisories/biden-administration-announces-approval-of-colorados-inclusive). For the 2027 plan year and beyond, the DOI updated the benchmark again to add coverage for abortion services. Colorado law already required carriers to cover abortion services starting in plan year 2025, so the update did not change that existing requirement (Colorado DOI, 2026, doi.colorado.gov/types-of-insurance/health-insurance/aca-information/aca-ehb-benchmark-health-insurance-plan).
| Benefit | What Colorado requires | Since |
|---|---|---|
| Annual mental health wellness exam | One 45 to 60 minute visit per plan year with a qualified mental health provider | 2023 benchmark |
| Alternatives to opioids (drugs) | 15 added drugs on formularies as alternatives to opioids | 2023 benchmark |
| Acupuncture | Up to six visits per year | 2023 benchmark |
| Gender-affirming care | Explicitly included; Colorado was the first state to do so | 2023 benchmark |
| Non-drug pain treatment (HB21-1276) | Cost sharing aligned for at least six physical therapy, six occupational medicine, six chiropractic and six acupuncture visits | State law, 2021 |
| Contraception and STI screening (SB21-016) | Contraception without cost sharing; STI screening for covered persons regardless of gender | State law, 2021 |
| Abortion services | Covered; added to the benchmark for 2027 | State law from plan year 2025; benchmark from 2027 |
The annual mental health wellness exam, explained
This is one of the most useful Colorado additions and one of the least known. According to the DOI, the visit can include behavioral health screening, education and consultation about healthy lifestyle changes, referrals to ongoing mental health treatment, and a discussion of possible medication options (Colorado DOI, October 12, 2021, doi.colorado.gov/news-releases-consumer-advisories/biden-administration-announces-approval-of-colorados-inclusive). It is a check-in, not a crisis service. If you have been meaning to talk to someone about stress, sleep or mood, this visit is built into Colorado individual and small-group plans for exactly that.
What you pay for it depends on the plan's cost sharing for mental health office visits. On the 2027 Colorado Option plans, mental and behavioral health office visits are $0 with no visit limit (Colorado Regulation 4-2-81, Appendix A, 2026, doi.colorado.gov/sites/doi/files/documents/Amended%20Regulation%204-2-81%20Concerning%20Colorado%20Option%20Standardized%20Health%20Benefit%20Plans_0.pdf). On other plans, read the mental health row of the plan's Summary of Benefits and Coverage.
The Colorado Option: the same benefits with set cost sharing
The Colorado Option is the state's standardized plan, created by HB21-1232 and available to everyone who buys individual coverage and to small employers with fewer than 50 employees (Colorado DOI, 2026, doi.colorado.gov/colorado-option). Every carrier selling individual plans must offer a Colorado Option plan at the bronze, silver and gold levels. These plans cover the same essential health benefits defined in Regulation 4-2-42, and carriers may not add benefits outside that list except reproductive health services approved by the DOI. What makes them different is that the state sets the cost sharing for the most common services, so two carriers' Colorado Option Silver plans charge the same copay for the same visit.
Regulation 4-2-81 sets the 2027 designs. Every tier has $0 preventive care, $0 mental and behavioral health and substance use office visits with no visit limit, $0 diabetes supplies including continuous glucose monitors, and a $5 copay for diabetes self-management education. Gold and silver also have $0 primary care visits with no limit, while bronze covers the first three primary care visits at $0, then the deductible applies, then a $50 copay.
| Plan | Deductible (individual) | Out-of-pocket maximum (individual) | Hospital stay, after deductible |
|---|---|---|---|
| Gold | $2,400 | $10,450 | 30% |
| Silver (on exchange) | $5,000 | $11,450 | 40% |
| Bronze | $8,100 | $11,200 | 50% |
| Silver 87% (cost-sharing reduction) | $1,100 | $3,600 | 30% |
| Silver 94% (cost-sharing reduction) | $200 | $2,300 | 20% |
A worked example: having a baby on a 2027 Colorado Option plan
Hypothetical Colorado household, not a real client. A 30-year-old in Brighton with self-only coverage is expecting a baby in 2027. Maternity and newborn care is an essential health benefit, so every ACA plan covers it. To keep the numbers honest, this example uses the federal coverage example every Summary of Benefits and Coverage must include, Peg is Having a Baby: nine months of in-network prenatal care and a hospital delivery, with a total example cost of $12,700 (CMS SBC template, November 2024, cms.gov/files/document/english-sbc-template-standard-format-110424.docx).
The template does not split the $12,700 between prenatal visits and the delivery, so this example takes a cautious approach and treats the whole amount as subject to the deductible and coinsurance. That overstates the cost, because prenatal and postnatal visits are $0 on every Colorado Option tier except bronze, where the first three are $0. The out-of-pocket maximum then caps the result.
| Plan | Deductible | Coinsurance on the rest | Total before cap | What you would pay |
|---|---|---|---|---|
| Gold | $2,400 | 30% of $10,300 = $3,090 | $5,490 | $5,490 |
| Silver | $5,000 | 40% of $7,700 = $3,080 | $8,080 | $8,080 |
| Bronze | $8,100 | 50% of $4,600 = $2,300 | $10,400 | $10,400 |
| Silver 87% | $1,100 | 30% of $11,600 = $3,480 | $4,580 | $3,600 (capped) |
| Silver 94% | $200 | 20% of $12,500 = $2,500 | $2,700 | $2,300 (capped) |
What the example shows
- The out-of-pocket maximum is the real protection. If the pregnancy had complications and costs ran far past $12,700, the silver plan's covered in-network costs would still stop at $11,450 for the year, and no plan could go above the $12,000 federal ceiling for 2027.
- The cost-sharing reduction silver plans change the math more than any other choice. Silver 87% and Silver 94% are only available through the Colorado marketplace to people whose income qualifies, and they hit their low caps quickly.
- Gold costs less at the time of care but usually more each month. Whether it pays off depends on the premium gap, which is why the premium has to sit next to these numbers.
- A baby born in 2027 also has a deadline: adding a newborn is a qualifying life event, and the plan's rules for adding a child should be read before the due date.
What is usually not included
- Adult dental and adult vision. Children's dental and vision are essential benefits; adult dental and routine adult eye care are not, so most adults buy them separately (see the dental and vision guides).
- Hearing aids for adults, in most plans.
- Long-term custodial care, such as help with bathing and dressing at home or in a facility.
- Cosmetic procedures and services the plan does not consider medically necessary.
- Services that are not essential health benefits can carry yearly or lifetime dollar limits, so read the limits column for anything outside the ten categories.
Plans that do not have to cover them
Short-term medical plans, fixed indemnity plans, critical illness policies and health care sharing ministries are not ACA plans and do not have to cover the essential health benefits. Some of them can be sensible add-ons, but none of them replaces a full ACA plan for most families. If you are offered a low price for something that skips maternity, mental health or prescriptions, that is usually the reason. Colorado regulates these products separately; the short-term medical and hospital indemnity guides explain the Colorado rules.
What Lisa checks for you
Lisa's approach is commonsense: ask questions, listen to the answers, and only then recommend the type of plan that fits. For essential health benefits, that means turning a list of ten categories into the handful of services a household will actually use.
- Your prescriptions on each finalist plan's drug list, with the tier, because drug coverage varies more than any other category.
- Your doctors, therapists and preferred hospital by name and location in each plan's network.
- The out-of-pocket maximum next to the premium, so you can see the cost of a bad year as well as an ordinary one.
- Whether a Colorado Option plan in your county matches your doctors, since its set copays make costs easier to predict.
- Whether your income may qualify you for a cost-sharing reduction silver plan through the Colorado marketplace.
- Visit limits on therapies you expect to use, such as physical therapy or chiropractic care.
- What sits outside the ten categories for your household, such as adult dental, vision or hearing, and whether a separate policy makes sense.
Questions to ask before you choose a plan
- Is each of my prescriptions on this plan's formulary, and on which tier?
- Are my doctors and my preferred hospital in network for 2027, not just this year?
- What is the out-of-pocket maximum, and is it embedded for each family member?
- Which services are covered before the deductible, and which only after it?
- Does this plan limit the number of visits for therapy, chiropractic care or acupuncture?
- How does this plan cover the annual mental health wellness exam?
- If this is not an ACA plan, which of the ten essential health benefits does it leave out?
How to check a plan before you buy
- Open the plan's Summary of Benefits and Coverage and find the services you expect to use.
- Search your prescriptions on the plan's drug list and note the tier.
- Confirm your doctors and preferred hospital are in network, by name and location.
- Look at the out-of-pocket maximum: it is the most you would pay for covered in-network care in a bad year.
- Put the yearly premium after any tax credit next to that maximum, and compare plans on both numbers together.
The bottom line
Essential health benefits are the floor every ACA plan in Colorado stands on, and Colorado builds on that floor with its own benchmark, from the annual mental health wellness exam to acupuncture and alternatives to opioids. Plans still differ on drugs, doctors and costs, and the out-of-pocket maximum decides what a bad year costs. If you would like Lisa to line up a few the Colorado marketplace plans against your own doctors and prescriptions, send her a message or call (303) 887-8584. There is no cost for her help.
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Sources
- Federal marketplace (CMS): What Marketplace health insurance plans cover, Centers for Medicare & Medicaid Services
- Federal marketplace (CMS): Lifetime and yearly limits, Centers for Medicare & Medicaid Services
- Federal marketplace (CMS): Out-of-pocket maximum limit, Centers for Medicare & Medicaid Services
- CMS: Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing and Required Contribution Percentage for the 2027 Benefit Year (January 29, 2026), Centers for Medicare & Medicaid Services
- Colorado Division of Insurance: ACA EHB Benchmark Health Insurance Plan, Colorado Division of Insurance
- Colorado Division of Insurance: CMS approval of Colorado's 2023 benchmark plan (October 12, 2021), Colorado Division of Insurance
- Colorado Division of Insurance: Proposed Additional Benefits for Health Coverage Plans, Colorado Division of Insurance
- Colorado Division of Insurance: Colorado Option, Colorado Division of Insurance
- Colorado Insurance Regulation 4-2-81, Appendix A: 2027 Colorado Option Standardized Plans, Colorado Division of Insurance
- CMS: Summary of Benefits and Coverage template (November 2024), Centers for Medicare & Medicaid Services
Please note: Headwaters Health and Wealth is not affiliated with, endorsed by, or operating on behalf of the Colorado marketplace, CMS, the Health Insurance Marketplace, or any federal or state government agency. Plan availability, premiums and advance premium tax credits are set by the carriers and the Marketplace.