TOWER OF THOUGHTS: Information on Essential Health Benefits (EHB) Benchmark Plans

Image of pregnant woman packing to go to the hospital

The Affordable Care Act requires non-grand fathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. HHS regulations (45 CFR 156.100) define EHB based on state-specific EHB benchmark plans. This page contains information on the EHB benchmark plans for each of the 50 states and the District of Columbia (D.C.). In plan years 2014 through 2016, the EHB benchmark plan is a plan that was sold in 2012. For plan year 2017 and beyond, the EHB benchmark plan is a
plan that was sold in 2014.

For plan years 2014-2016, two documents are provided for each EHB benchmark plan in the 50 states and D.C.: (1) a summary of the plan's benefit coverage and limits, including a list of covered prescription drug categories and classes; and (2) a list of state-required benefits.
The list of each state's required benefits has been compiled to help states and issuers determine which state-required benefits must be included in plan designs.
For 2017, three documents are provided for each EHB benchmark plan: (1) a summary of the plan’s coverage of certain benefits that appear on the Plans & Benefits Template, including a list of covered prescription drug categories and classes; (2) supporting plan documents that provide detail regarding all plan coverage, limits, and exclusions; and (3) an updated list of state-required benefits. Information on plans used to supplement benchmark plans that are missing one or more categories of benefits is also provided, as applicable.

Final 2017 Essential Health Benefits (EHB) Benchmark Plans

Please click here to view the final 2017 EHB benchmark plans for the 50 states and D.C. Additional information regarding each plan is available by selecting a particular state below. During the public comment period, which closed on on September 30, 2015, the Alaska, Arizona, California, Hawaii, Idaho, Kansas, Michigan, Missouri, Montana, New Hampshire, New Mexico, North Carolina, Ohio, Oregon, South Carolina, South Dakota, Utah, Virginia, and Wyoming submitted changes to their respective EHB benchmark plans summary documents. These changes have been incorporated into the final EHB benchmark plan summary documents.
Because EHB benchmark plan benefits are based on plans that were sold in 2012 or 2014, some of the benchmark plan designs may not comply with current federal requirements. Therefore, when designing plans that are substantially equal to the EHB benchmark plan, issuers may need to conform plan benefits, including coverage and limitations, to comply with these requirements and limitations, including but not limited to the following:

Supplementing the Benchmark

If one or more categories of benefits is missing in the benchmark plan, the issuer must supplement it as noted in 45 CFR 156.110(b)-(c). Pediatric dental and vision must be supplemented with the FEDVIP dental plan with the largest national enrollment or the benefits in the state’s separate CHIP plan. Please click here to view FEDVIP details.

Annual and Lifetime Dollar Limits

The EHB benchmark plans displayed may include annual and/or lifetime dollar limits; however, in accordance with 45 CFR 147.126, these limits cannot be applied to the essential health benefits. Annual and lifetime dollar limits can be converted to actuarially equivalent treatment or service limits.

Coverage Limits

Pursuant to 45 CFR 156.115(a)(2), with the exception of coverage for pediatric services, a plan may not exclude an enrollee from coverage in an entire EHB category, regardless of whether such limits exist in the EHB benchmark plan. For example, a plan may not exclude dependent children from the category of maternity and newborn coverage.

EHB Benchmark Plan Prescription Drug Coverage by Category and Class

Please note that in some cases a prescription drug category is listed without a United States Pharmacopeia (USP) class because there are some drugs within the category that have not been assigned to a specific class.
Please also note that, pursuant to 45 CFR 156.122, if the EHB benchmark plan does not include any coverage in a USP category and/or class (count is zero), EHB plans must cover at least one drug in that USP category and/or class.

Excluded Benefits

Pursuant to 45 CFR 156.115, the following benefits are excluded from EHB even though an EHB benchmark plan may cover them: routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, and/or non-medically necessary orthodontia. Please also note that although the EHB benchmark plan may cover abortion services, pursuant to section 1303(b)(1)(A) of the Affordable Care Act, a QHP issuer is not required to cover these services. Section 156.115(c) provides that no health plan is required to cover abortion services as part of the requirement to cover EHB. Nothing in this provision impedes an issuer's ability to choose to cover abortion services or limits a state's ability to either prohibit or require these services under state law.

Habilitative Services and Devices

The EHB benchmark plans displayed may not include coverage of habilitative services and devices. Pursuant to 45 CFR 156.110(f), the State may determine which services are included in the habilitative services and devices category if the base-benchmark plan does not include such coverage. If the State does not supplement the missing habilitative services and devices category, issuers should cover habilitative services and devices as defined in 45 CFR 156.115(a)(5)(i).

Mental Health Parity

The EHB benchmark plans displayed may not comply with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). However, as described in 45 CFR 156.115(a)(3), EHB plans must comply with the standards implemented under MHPAEA, including standards that are effective in the 2017 plan year.

Preventive Services

The EHB benchmark plans displayed may not offer the preventive services described in 45 CFR 147.130. However, as described in 45 CFR 156.115(a)(4), EHB plans must comply with that section.

State-Required Benefits

For purposes of determining EHB, state-required benefits (or mandates) are considered to include only requirements that a health plan cover specific care, treatment, or services. Provider mandates, which require a health plan to reimburse specific health care professionals who render a covered service within their scope of practice, are not considered to be state-required benefits for purposes of EHB coverage. Similarly, state-required benefits are not considered to include dependent mandates, which require a health plan to define dependents in a specific manner or to cover dependents under certain circumstances (e.g., newborn coverage, adopted children, domestic partners, and disabled children). Finally, state anti-discrimination requirements relating to service delivery method (e.g., telemedicine) are not considered to be state-required benefits.

Essential Health Benefits Benchmark Plans

Wednesday, 8 June 2016

Information on Essential Health Benefits (EHB) Benchmark Plans