ESSENTIAL HEALTH BENEFITS BENCHMARK PLAN - 2017 AND YEARS THEREAFTER
Pursuant to Section 1302 of the Affordable Care Act and federal rule 45 CFR 156.100, the Commonwealth of Massachusetts (“Commonwealth”) has selected the base-benchmark plan[1] for coverage year 2017 and years thereafter. The EHB Benchmark Plan[2] defines the Essential Health Benefits (EHBs) to be included in all small group and individual plans (merged market plans) offered in the state, both within and outside of the Marketplace (the Health Connector). For the 2017 plan year and years thereafter, the Commonwealth has selected the HMO Blue New England $2000 Deductible Plan (“HMO Blue New England”) offered by Blue Cross Blue Shield of Massachusetts HMO Blue, Inc. as its base-benchmark Plan . The HMO Blue New England plan will be supplemented with the Commonwealth of Massachusetts CHIP plan for pediatric dental benefits and the FEDVIP plan for pediatric vision benefits. The HMO Blue New England plan, as supplemented with the Commonwealth CHIP plan and the FEDVIP plan, will constitute the year 2017 and thereafter EHB Benchmark Plan for Massachusetts, with the following qualifications:
EHBs will include:
- all services within the base-benchmark plan, as supplemented (except as noted below);
- state mandated benefits enacted before 1-1-12;
- behavioral health benefits required under the ACA and federal MHPAEA;
- habilitative services which meet the definition found in 45 CFR §156.115(a)(5)(i).
- Moreover, EHB-compliant plans shall not impose: (1) combined limits on habilitative and rehabilitative services and devices; and (2) limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices;
- any preventive services required by ACA that may not be in the base-benchmark plan; and
- coverage for prescription drugs pursuant to 45 CFR §156.122.
- If the HMO Blue New England plan does not include any drug in a USP category and/or class (count is zero), EHB-compliant plans must cover at least one drug in that USP category and/or class.
EHBs will not include:
- state mandates enacted on or after 1-1-12;
- non-pediatric dental services;
- routine non-pediatric eye exam services;
- long-term/custodial nursing home care benefits; and/or
- non-medically necessary orthodontia.
EHBs may not have any annual or lifetime dollar limit. However, the carrier may substitute an actuarially equivalent limit that is not a dollar limit (for example, one designated wig). Benefits that are not considered EHBs may have annual or dollar limits (for example, the hearing aid mandate).
The carrier may substitute another benefit for an EHB as long as it is actuarially equivalent and within the same category of service.
Although state mandates enacted on or after 1-1-12 are not considered EHBs, they must be included in all plans offered. The carrier may not substitute an actuarial equivalent for a state mandated benefit.
With the exception of coverage for pediatric services, an enrollee may not be excluded from coverage in an entire EHB category.
Please also refer to CMS document “Information on Essential Health Benefits (EHB) Benchmark Plans at https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html
Links for The HMO Blue New England $2000 Deductible Plan, the Commonwealth of Massachusetts CHIP plan for dental benefits and the FEDVIP plan for vision benefits are provided below.
- HMO Blue® New England $2,000 Deductible Plan Option file size 2MB
- The Children’s Health Insurance Program “CHIP” Dental Plan file size 1MB
- Federal Employees Vision Insurance Program
- Benchmark Formulary file size 2MB
[1] Base-benchmark plan means the plan that is selected by a State from the options described in 45 CFR §156.100(a), or a default benchmark plan, as described in 45 CFR §156.100(c), prior to any adjustments made pursuant to the benchmark standards described in 45 CFR §156.110. See 45 CFR§156.20
[2] EHB-benchmark plan means the standardized set of essential health benefits that must be met by a Qualified Health Plan, as defined in 45 CFR §155.20, or other issuer as required by 45 CFR §147.150. See 45 CFR §156.20