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    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.