45 CFR 156.110 – EHB-benchmark plan standards
An EHB-benchmark plan must meet the following standards:
(a) EHB coverage. Provide coverage of at least the following categories of benefits:
(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.
(10) Pediatric services, including oral and vision care.
(b) Coverage in each benefit category. A base-benchmark plan not providing any coverage in one or more of the categories described in paragraph (a) of this section, must be supplemented as follows:
(1) General supplementation methodology. A base-benchmark plan that does not include items or services within one or more of the categories described in paragraph (a) of this section must be supplemented by the addition of the entire category of such benefits offered under any other benchmark plan option described in § 156.100(a) of this subpart unless otherwise described in this subsection.
(2) Supplementing pediatric oral services. A base-benchmark plan lacking the category of pediatric oral services must be supplemented by the addition of the entire category of pediatric oral benefits from one of the following:
(i) The FEDVIP dental plan with the largest national enrollment that is described in and offered to federal employees under 5 U.S.C. § 8952; or
(ii) The benefits available under that State’s separate CHIP plan, if a separate CHIP plan exists, to the eligibility group with the highest enrollment.
(3) Supplementing pediatric vision services. A base-benchmark plan lacking the category of pediatric vision services must be supplemented by the addition of the entire category of pediatric vision benefits from one of the following:
(i) The FEDVIP vision plan with the largest national enrollment that is offered to federal employees under 5 USC 8982; or
(ii) The benefits available under the State’s separate CHIP plan, if a separate CHIP plan exists, to the eligibility group with the highest enrollment.
(c) Supplementing the default base-benchmark plan. A default base-benchmark plan as defined in § 156.100(c) of this subpart that lacks any categories of essential health benefits will be supplemented by HHS in the following order, to the extent that any of the plans offer benefits in the missing EHB category:
(1) The largest plan by enrollment in the second largest product by enrollment in the State’s small group market, as defined in § 155.20 of this subchapter (except for pediatric oral and vision benefits);
(2) The largest plan by enrollment in the third largest product by enrollment in the State’s small group market, as defined in § 155.20 of this subchapter (except for pediatric oral and vision benefits);
(3) The largest national FEHBP plan by enrollment across States that is offered to federal employees under 5 USC 8903 (except for pediatric oral and vision benefits);
(4) The plan described in paragraph (b)(2)(i) of this section for pediatric oral care benefits; and
(5) The plan described in paragraph (b)(3)(i) of this section for pediatric vision care benefits.
(d) Non-discrimination. Not include discriminatory benefit designs that contravene the non-discrimination standards defined in § 156.125 of this subpart.
(e) Balance. Ensure an appropriate balance among the EHB categories to ensure that benefits are not unduly weighted toward any category.
(f) Determining habilitative services. If the base-benchmark plan does not include coverage for habilitative services, the State may determine which services are included in that category.