Form CMS-10488 EHB Confirmation Template

Confirmations on the State's EHB-benchmark Plan
Instructions: All fields on this template are required. Please make sure to answer all fields and confirm that the new EHB-benchmark Plan covers all 10 EHB
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.
Points of Contact for the State's EHB- benchmark Plan Selection

Primary

Secondary

Name
Agency
Phone Number
Email
State
Under which option of 45 CFR 156.111(a), is the State selecting its new EHBbenchmark Plan?

§ 156.111(a)(1) – Select the EHB-benchmark plan from another
State

For what plan year is the State selecting its new EHB-benchmark Plan to begin
applying?
If using §156.111(a)(1), which other State's EHB-benchmark Plan is the State using for
its EHB-benchmark plan?
Criteria for a State EHB-benchmark Plan at 45 CFR 156.111

Does the State's EHB-benchmark Plan cover the 10 EHB Categories in accordance
with 45 CFR 156.110(a)?

Does the State's EHBbenchmark Plan cover the
category?

If the State's is using
§156.111(a)(2), select the other
State's EHB-benchmark Plan
being used for the particular
category

State's Confirmations

Explanation

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*
If the State is using the option under §156.111(a)(3), did the State
provide a complete and accurate formulary drug list under the
Appendix D entitled “Rx Template” in this workbook?
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventative, wellness, and chronic disease management
10. Pediatric services, including oral and vision care
Does the State's EHB-benchmark Plan definition meet the requirements of
§156.111(b)(1) with regard to scope of benefits?
Is the State's EHB-benchmark Plan equal to, or greater than, to the extent any
supplementation is required to provide coverage within each EHB category at
§156.110(a), the scope of benefits provided under a typical employer plan as defined
and established at §156.111(b)(2)(i)?
Has an actuary, who is a member of the American Academy of Actuaries, in
accordance with generally accepted actuarial principles and methodologies, affirmed
that the State's new EHB-benchmark plan provides a scope of benefits that is equal
to, or greater than, to the extent any supplementation is required to provide
coverage within each EHB category at §156.110(a), to the scope of benefits to a
typical employer plan as required at §156.111(b)(2)(i) and in accordance with
§156.111(e)(2)?
Is the State's EHB-benchmark Plan does not exceed the generosity of the most
generous the plans listed at §156.111(b)(2)(ii) ?
Has an actuary, who is a member of the American Academy of Actuaries, in
accordance with generally accepted actuarial principles and methodologies, affirmed
that the new EHB-benchmark plan does not exceed the generosity of the most
generous the plans listed at §156.111(b)(2)(ii) and in accordance with §156.111(e)(2)?
Is the State's EHB-benchmark Plan unduly weighting benefits towards any of the
categories of benefits (§156.111(b)(2)(iii))?
Does the State's EHB-benchmark Plan provide benefits for diverse segments of the
population in accordance with §156.111(b)(2)(iv)?
Did the State provide reasonable public notice and an opportunity for public
comment on the State's selection of its EHB-benchmark Plan that includes posting a
notice on its opportunity for public comment with associated information on a
relevant State Web site in accordance with §156.111(c)?
Are non-EHB benefits excluded from the EHB-benchmark Plan in accordance with
§156.115(d)? (Non-EHB benefits include adult vision, adult dental, long-term care,
cosmetic orthodontia)
Has the State converted any benefits in its EHB-benchmark Plan restricted by annual
or lifetime dollar limits as defined by §147.126 to non-dollar limit benefits?
Does the EHB-benchmark Plan include benefits mandated by State action taking place
after 2011, other than for purposes of compliance with Federal requirements, for
which payment is required under §155.170?
Are the EHB-benchmark Plan's benefits designed such that they do not discriminate
based on an individual's age, expected length of life, present or predicted disability,
degree of medical dependency, quality of life, or other health conditions as
prohibited by §156.125 in accordance §156.111(b)(2)(v)?
* Note: Due to the availability of drugs in the market, the exact drug count for a given State will be established in the EHB drug count tool, but for the
purposes of the State's EHB- benchmark Plan, the display will be the same drug count as the 2017 EHB-benchmark plan.