Information on Essential Health Benefits (EHB) Benchmark Plans

Information on Essential Health Benefits (EHB) Benchmark Plans

The Affordable Care Act requires non-grandfathered health insurance coverage in the individual and small group markets to cover essential health benefits (EHB), which include items and services in at least 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 was 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 was 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). For the 2022 plan year, CMS approved changes to the Michigan EHB-benchmark plan (ZIP), to the New Mexico EHB-benchmark plan (ZIP), and to the Oregon EHB-benchmark plan (ZIP). For the 2023 plan year, CMS approved changes to the Colorado EHB-benchmark plan (ZIP). For the 2024 plan year, CMS approved changes to the Vermont EHB-benchmark plan (ZIP). For the 2025 plan year, CMS approved changes to the North Dakota EHB-benchmark plan (ZIP), and the Virginia EHB-benchmark plan (ZIP). For the 2026 plan year, CMS approved changes to the Alaska EHB-benchmark plan (ZIP), the District of Columbia EHB-benchmark plan (ZIP), and the Washington EHB-benchmark plan (ZIP). States that opted not to exercise this flexibility continue to use the same EHB-benchmark plan from plan year 2017.

The Final 2025 HHS Notice of Benefits and Payment Parameters finalized several EHB policies related to the following subject areas: 1) EHB-Benchmark Plan Update Process Improvements, 2) Routine Adult Dental Services, 3) Prescription Drug Benefits, and 4) State-Mandated Benefits and Defrayal. We encourage states and issuers to review these policy changes in the final rule and the CMS Fact Sheet for further information.

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EHB-Benchmark Plans for Plan Year 2020 and Beyond

EHB-Benchmark Plan Selection Process for Plan Year 2020 through Plan Year 2025

CMS provided States with greater flexibility to select their EHB-benchmark plan by providing three options for selection to apply in their markets in plan year 2020 through plan year 2025, 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 the State's 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).

Template and Documentation Requirements for Plan Year 2020 through Plan Year 2025

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:

  1. EHB State Confirmation Template,
  2. Actuarial Certification/Report,
  3. EHB-Benchmark Plan Document
  4. EHB-Benchmark Summary Chart Template, and
  5.  Formulary Drug List Template (generally only required for Option 3).

EHB-Benchmark Plan Selection Process for Plan Year 2026 and Beyond

In the Final 2025 HHS Notice of Benefits and Payment Parameters, CMS finalized consolidating these three options for states to change EHB-benchmark plans, such that a state may change its EHB-benchmark plan by selecting a set of benefits that would become the state’s EHB-benchmark plan (option 3). This change will apply for plan years beginning on or after January 1, 2026.

Template and Documentation Requirements for Plan Year 2026 and Beyond

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 for plan years beginning on or after January 1, 2026, the State must submit the:

  1. EHB State Confirmation Template,
  2. Actuarial Certification/Report,
  3. EHB-Benchmark Plan Document,
  4. EHB-Benchmark Summary Chart Template, and
  5. Formulary Drug List Template (only if a state only is changing its prescription drug EHBs).

In the Final 2025 HHS Notice of Benefits and Payment Parameters, CMS removed the requirement for states to submit a formulary drug list as part of their documentation to change EHB-benchmark plans unless the state changes its prescription drug EHBs. This change will apply for plan years beginning on or after January 1, 2026.

The below chart describes State documentation requirements.

State Documentation RequirementsDefine the State's EHB-benchmark Plan

Required?
Confirmations:
Complies with §156.111(a), (b), and (c)		Yes
Actuarial certification and report:
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		Yes
Benefits and limits/State’s EHB-benchmark plan document:
1. Describes benefits and limits in accordance with §156.111(e)(3)		Yes
2. Provides formulary drug list for the State's EHB-benchmark PlanYes, only if a state is changing its prescription drug EHBs. 
 
EHB Summary Chart:
Provides a summary of the State's EHB-benchmark Plan		Yes

Overview of Current Essential Health Benefits (EHB) Benchmark Plans

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 through plan year 2025, 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 plan year 2026 and beyond, the Final 2025 HHS Notice of Benefits and Payment Parameters revised 45 CFR 156.111 such that the standards for state selection of EHB-benchmark plans address long-standing requests from states to improve, and reduce the burden of, the EHB-benchmark plan update process.

For the 2020 plan year and beyond, CMS approved changes to the Illinois EHB-benchmark plan (ZIP). For the 2021 plan year and beyond, CMS approved changes to the South Dakota EHB-benchmark plan (ZIP). For the 2022 plan year and beyond, CMS approved changes to the Michigan EHB-benchmark plan (ZIP), to the New Mexico EHB-benchmark plan, (ZIP) and to the Oregon EHB-benchmark plan (ZIP). For the 2023 plan year and beyond, CMS approved changes to the Colorado EHB-benchmark plan (ZIP). For the plan year 2024 and beyond, CMS approved changes to the Vermont EHB-benchmark plan (ZIP). For the 2025 plan year and beyond, CMS approved changes to the North Dakota EHB-benchmark plan (ZIP), and the Virginia EHB-benchmark plan (ZIP). For the 2026 plan year, CMS approved changes to the Alaska EHB-benchmark plan (ZIP), the District of Columbia EHB-benchmark plan (ZIP), and the Washington EHB-benchmark plan (ZIP). States that opted not to exercise this flexibility continue to use the same EHB-benchmark plan in effect since plan year 2017.

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 based are plans from plan year 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.

Coverage Limits

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

EHB Benchmark Plan Prescription Drug Coverage by Category and Class

Plans subject to EHB requirements must comply with 45 CFR 156.122(a)(1) to cover at least the same number of prescription drugs in every category and class in the United States Pharmacopeia (USP) Medicare Model Guidelines (MMG) as covered by the State's EHB-benchmark plan, or one drug in every category and class, whichever is greater. The USP MMG is an independent drug classification system. CMS routinely updates EHB-benchmark plans to reflect the most up-to-date version of the USP MMG available. When a new version of USP MMG is published, CMS updates state EHB-benchmark plans to reflect the new version, starting with the plan year after the new version of the USP MMG is available.

Please note that in some cases a prescription drug category is listed without a 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(d), the following benefits are excluded from EHB even though an EHB-benchmark plan may cover them: routine non-pediatric dental services (for plan years beginning on or before January 1, 2026), routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, and/or non-medically necessary orthodontia. For plan years beginning on or after January 1, 2027, an issuer of a plan offering EHB may include routine non-pediatric dental services. 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.

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 include preventive services described in that section.

State-Required Benefits

For purposes of determining EHB, State-required benefits (or mandates) are considered to include only State requirements for issuers 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).

Also please note that the Final 2025 HHS Notice of Benefits and Payment Parameters finalized at 45 CFR 155.170  that a benefit required by State action taking place on or before December 31, 2011, a benefit required by State action for purposes of compliance with Federal requirements, or a benefit covered in the State’s EHB-benchmark plan is considered an EHB.

Essential Health Benefits Benchmark Plans

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 |

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

Page Last Modified:
10/17/2024 03:53 PM
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