Under ACA Section 1302, all individual and small group health insurance plans (50 or fewer employees) sold in Florida must cover 10 categories of 'Essential Health Benefits' (EHB). Each state defines its EHB benchmark plan that sets the specific coverage standards for each category. Florida's benchmark is the Blue Cross Blue Shield of Florida HMO plan from 2017. Self-funded plans and large group plans (50+ EE) are exempt from EHB requirements but still subject to other federal mandates.
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Florida's benchmark plan is the Blue Cross Blue Shield of Florida HMO plan from 2017 (specifically the BlueOptions plan). The benchmark sets the standard for what each of the 10 EHB categories must include. Other carriers (UnitedHealth, Aetna, Cigna, Ambetter) must offer at least equivalent coverage in each category.
The benchmark is reviewed periodically by HHS — Florida's benchmark may update in future years.
Pediatric dental and vision are required EHBs in the small group market. They can be embedded in the medical plan OR offered as separate stand-alone dental/vision plans. Most Florida small group medical plans offer pediatric dental as embedded; vision typically requires a separate plan.
EHB categories CANNOT be subject to annual or lifetime dollar limits. Pre-ACA plans commonly had $1M-$5M lifetime caps; ACA prohibits this for EHB services.
| Item | 2026 Limit |
|---|---|
| Out-of-pocket maximum (single) | $9,200 |
| Out-of-pocket maximum (family) | $18,400 |
| Out-of-pocket max for HSA-qualified HDHP (single) | $8,300 |
| Out-of-pocket max for HSA-qualified HDHP (family) | $16,600 |
Plans cannot impose higher OOP limits on EHB services. Non-EHB services CAN exceed the OOP limit.
| Plan Type | EHB Required? |
|---|---|
| Florida small group ACA-compliant | Yes — full 10 categories |
| Individual ACA marketplace | Yes |
| Large group (50+ EE) fully insured | No (still has annual/lifetime limits prohibition for any covered EHB) |
| Self-funded plans | No (governed by ERISA) |
| Grandfathered plans (pre-2010) | No (limited grandfather status) |
| Excepted benefits (dental-only, vision-only, etc.) | No |
A licensed Florida broker can review your current plan against the EHB benchmark.
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