The Center for Consumer Information & Insurance Oversight
Information on Essential Health Benefits (EHB) Benchmark Plans
The Affordable Care Act requires non-grandfathered 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, et seq.) define EHB based on State-specific EHB-benchmark plans. Below are 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. Those 2014-2016 EHB-benchmark plans and associated materials can be found here. For plan years 2017, 2018, and 2019, each State’s EHB-benchmark plan is based on a plan that was sold in 2014. For plan year 2020 and after, the Final 2019 HHS Notice of Benefits and Payment Parameters promulgated 45 CFR 156.111, which provides States with greater flexibility by establishing new standards for States to update their EHB-benchmark plans, if they so choose. For the 2020 plan year, CMS approved changes to the Illinois EHB-benchmark plan (ZIP). For the 2021 plan year, CMS approved changes to the South Dakota EHB-benchmark plan (ZIP). States that opted not to exercise this flexibility continue to use the same EHB-benchmark plan from plan years 2017-2019.
For plan years 2020 and 2021, no State opted to permit issuers to substitute benefits between benefit categories, pursuant to 45 CFR 156.115(b)(2)(ii).
- EHB-Benchmark Plan Selection Process for Plan Year 2020 and Beyond
- Template and Documentation Requirements for Plan Year 2020 and Beyond
- Overview of Current Essential Health Benefits (EHB) Benchmark Plans
- Current EHB-benchmark plan documents by State
Plan Year 2020 and Beyond EHB-Benchmark Plans
CMS provided States with greater flexibility to select its EHB-benchmark plan by providing three new options for selection in plan year 2020 and beyond, including:
- Option 1: Selecting the EHB-benchmark plan that another State used for the 2017 plan year.
- Option 2: Replacing one or more categories of EHBs under its EHB-benchmark plan used for the 2017 plan year with the same category or categories of EHB from the EHB-benchmark plan that another State used for the 2017 plan year.
- Option 3: Otherwise selecting a set of benefits that would become the State’s EHB-benchmark plan.
Under each of these three options, the new EHB-benchmark also must comply with additional requirements, including scope of benefits requirements, under 45 CFR 156.111(b).
In accordance with 45 CFR 156.111(a), States may choose to select a new EHB-benchmark plan to be applicable starting in plan year 2020. To select a new EHB-benchmark plan, the State must submit:
- EHB State Confirmation Template,
- Actuarial Certification/Report,
- EHB-Benchmark Plan Document, and
- EHB-Benchmark Summary Chart Template.
The Formulary Drug List Template is generally only required for Option 3. The below chart describes State documentation requirements for each selection option.
|State Documentation Requirements||
Option 1: Select another State's EHB-benchmark Plan
Option 2: Replace category or categories of benefits from another State's EHB-benchmark Plan
Option 3: Otherwise define the State's EHB-benchmark Plan
Complies with §156.111(a), (b), and (c)
Actuarial certification and report:
1. Equal to, or greater than, to the extent any supplementation is required to provide coverage within each EHB category, the scope of benefits provided under a typical employer plan
|2. Does not exceed the generosity of the most generous among the plans listed at §156.111(b)(2)(ii)||Yes||Yes||Yes|
Benefits and limits/State’s EHB-benchmark plan document:
1. Describes benefits and limits in accordance with §156.111(e)(3)
2. Provides formulary drug list for the State's EHB-benchmark Plan
|No||No, unless the a State is replacing its prescription drug coverage under option 2||Yes|
EHB Summary Chart:
Provides a summary of the State's EHB-benchmark Plan
Please click here (PDF) to view a consolidated list of the EHB-benchmark plans for the 50 states and D.C. that states used for at least plan years 2017, 2018, and 2019. Additional information regarding each of these plans is available by selecting a particular State below. During the public comment period for selection of the plan year 2017-2019 EHB-benchmark plans, which closed on September 30, 2015, 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 were incorporated into the final EHB -benchmark plan summary documents.
For plan year 2020 and after, the Final 2019 HHS Notice of Benefits and Payment Parameters promulgated 45 CFR 156.111, which provides States with greater flexibility by establishing new standards for States to update their EHB-benchmark plans, if they so choose. For 2020, CMS approved changes to the Illinois benchmark plan (ZIP). For the 2021 plan year, CMS approved changes to the South Dakota EHB-benchmark plan. States that opted not to exercise this flexibility continue to use the same EHB-benchmark plan from plan years 2017-2019.
Please click here to view the EHB-benchmark plans for the 50 States and D.C. that were applicable for plan years 2014-2016.
Because the base-benchmark plans on which some current EHB-benchmark plans were 2014 plans, some of the EHB-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 current requirements and limitations, including but not limited to the following:
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.
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.
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, 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 Paul Wellstone and Pete Domenici 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.
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.
For purposes of determining EHB, State-required benefits (or mandates) are considered to include only requirements to cover specific care, treatment, or services. Provider mandates that require reimbursement of 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 defining dependents in a specific manner or covering 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.
For more information on State-required benefits, please refer to the FAQ on Defrayal of State Additional Required Benefits (PDF).
To view the current EHB-benchmark plan for a particular State, please select the State below.
Please click here to view the EHB-benchmark plans for the 50 states and D.C. that were applicable for plan years 2014-2016.
Alabama | Alaska | Arizona | Arkansas | California | Colorado | Connecticut | Delaware | District of Columbia | Florida | Georgia |Hawaii | Idaho | Illinois | Indiana | Iowa | Kansas | Kentucky | Louisiana | Maine | Maryland | Massachusetts | Michigan | Minnesota | Mississippi | Missouri | Montana | Nebraska | Nevada | New Hampshire | New Jersey | New Mexico | New York | North Carolina | North Dakota | Ohio | Oklahoma | Oregon | Pennsylvania | Rhode Island | South Carolina | South Dakota | Tennessee | Texas | Utah | Vermont | Virginia | Washington | West Virginia | Wisconsin | Wyoming |
- State-required benefits
- 2017-2019 EHB Benchmark Plan Information (ZIP)
- 2020-2021 EHB Benchmark Plan Information (ZIP)
- State-required benefits
- 2017-2020 EHB Benchmark Plan Information
- 2021 EHB-Benchmark Plan Information (ZIP)
- November 5, 2019 FAQ: Quality Rating Information Bulletin’s (Quality Bulletin’s) Display Guidelines for Direct Enrollment (DE) Entities
- November 1, 2019 Enhanced Direct Enrollment Approved Partners (Updated)
- September 11, 2019 FAQ: Enhanced Direct Enrollment Participation Requirements for Non-Issuer of a Primary EDE Entity Environment
- August 15, 2019 Quality Rating Information Bulletin for Plan Year 2020 Health Insurance Exchanges Quality Rating System (QRS) for Plan Year (PY) 2019: Results at a Glance
- April 18, 2019 CMS-9926-F: Final HHS Notice of Benefit and Payment Parameters for 2020 Final 2020 Letter to Issuers on Federally-facilitated Exchanges Key Dates for Calendar Year 2019: QHP Certification in the FFEs; Rate Review; Risk Adjustment
- April 4, 2019 Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2019 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2020
- March 19, 2019 2020 Final Actuarial Value Calculator 2020 Final Actuarial Value Calculator Methodology
- March 6, 2019 CMS-9921-NC: Request for Information Regarding the Sale of Individual Health Insurance Coverage Across State Lines Through Health Care Choice Compacts
- February 28, 2019 Section 1332 Pass-through Funding Tools and Resources