Beginning in 2014, the Affordable Care Act requires non-grand fathered health plans 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. The essential health benefits should be equal in scope to a typical employer health plan.
In the Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation Final Rule ("EHB Rule"), HHS defines EHB based on state-specific EHB-benchmark plans. This page contains information on EHB-benchmark plans for each of the 50 states, the District of Columbia (D.C.), and the U.S. territories. Two documents are provided for each EHB-benchmark plan in the 50 states, D.C. and Puerto Rico: (1) a summary of the plan's specific benefits and limits, and list of covered prescription drug categories and classes; and (2) state-required benefits.
The summaries of the covered benefits and limits, and lists of prescription drug categories and classes have been compiled based on the EHB-benchmark plan selection process described in 45 CFR 156.100 and 156.110. These summaries describe the EHB-benchmark plans that have been selected by states, as well as those that have been developed by HHS using the default benchmark plan selection process described in 45 CFR 156.100(c) and the supplementation methodology in 45 CFR 156.110.
A “Revised Benchmark Benefits” spreadsheet is also provided for each state. That spreadsheet lists important state-and CMS-identified corrections to the benefit data that is auto-populated. Therefore, issuers should refer to the “Revised Benchmark Benefits” spreadsheet when completing the Benefits Package Worksheet of the Plans and Benefits Template. If there is conflicting information on the Summary of Benefits and Limits, issuers should rely on the “Revised Benchmark Benefits” spreadsheets for the most up-to-date coverage information.
Because EHB-benchmark plan benefits are based on 2012 plan designs, and include state-required benefits that were enacted before December 31, 2011, some of the benchmark plan summaries may not reflect requirements effective for plan years starting on or after January 1, 2014. Therefore, when designing plans that are substantially equal to the EHB-benchmark plan, beginning in 2014, issuers may need to conform plan benefits, including coverage and limitations, to comply with these requirements and limitations.
A list of each state's required benefits has also been compiled to help states and issuers determine the state-required benefits in excess of EHB. We consider state-required benefits (or mandates) to include only specific care, treatment, or services that a health plan must cover. We do not consider provider mandates, which require a health plan to reimburse specific health care professionals who render a covered service within their scope of practice, to be state-required benefits for purposes of EHB coverage. Similarly, we do not consider state-required benefits 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, we do not consider state anti-discrimination requirements, and state requirements relating to service delivery method (e.g., telemedicine) to be state-required benefits.
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Essential health benefits (EHB)-benchmark plans are based on 2012 plan designs, and therefore do not necessarily reflect requirements effective for plan years beginning on or after January 1, 2014. Therefore, when designing plans that are substantially equal to the EHB-benchmark plan beginning January 1, 2014, issuers may need to design plan benefits, including coverage and limitations, to comply with these requirements and limitations, including but not limited to, the following:
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.
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.
If the EHB-benchmark plan does not cover any habilitative services and the state does not define those benefits, then pursuant to 45 CFR 156.115(a)(5), the issuer determines which habilitative services to offer as a part of a two year transitional policy.
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.
For purposes of determining EHB, we consider state-required benefits (or mandates) to include only requirements that a health plan cover specific care, treatment, or services. We do not consider provider mandates, which require a health plan to reimburse specific health care professionals who render a covered service within their scope of practice, to be state-required benefits for purposes of EHB coverage. Similarly, we do not consider state-required benefits 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, we do not consider state anti-discrimination requirements relating to service delivery method (e.g., telemedicine) as state-required benefits.
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.
Please note that in some cases a 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 where the EHB-benchmark plan does not include coverage in a USP category and/or class, pursuant to 45 CFR 156.122, one drug would have to be offered in that USP category and/or class.
In conjunction with the policy that plans must offer the greater of one drug in every USP category and class or the number of drugs in each USP category and class offered by the EHB-benchmark, HHS is considering developing a drug counting service to assist states and issuers with implementation of the proposed prescription drug policy, as described in the following methodology document:
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.