CMS-10448 EHB Benchmark Plan Certification

OMB Control Number: 0938-1174
Expiration Date: XX/XX/2021

Appendix B
State Essential Health Benefits-benchmark Plan Actuarial
Certification

State:

The actuarial report associated with this certification should be submitted as an attachment to this
actuarial certification.
1. Which EHB-benchmark plan option (at 45 CFR §156.111(a)) is the State using to make changes to its
EHB-benchmark plan (select one)?
 (a)(1) - Selecting the EHB-benchmark plan that another State used for the 2017 plan year under
§156.100 and §156.110
 (a)(2) - Replacing one or more categories of EHBs under §156.110(a) under its EHB-benchmark
plan used for the 2017 plan year with the same category or categories of EHB from the EHBbenchmark plan that another State used for the 2017 plan year under §156.100 and §156.110.
 (a)(3) - Otherwise selecting a set of benefits that would become the State’s EHB-benchmark
plan.
Section 1: Typical Employer Plans Determination for §156.111(b)(2)(i)
2. Which definition of a typical employer plan at §156.111(b)(2)(i) was used for the determination under
this actuarial certification and associated report?
One of the selecting State’s 10 benchmark plan options established at §156.100 of this subpart,
and available for the selecting State’s selection for the 2017 plan year.
The largest health insurance plan by enrollment within one of the five largest large group health
insurance products by enrollment in the State, as product and plan are defined at §144.103,
provided that: (1) The product has at least ten percent of the enrollment among the five largest
large group health insurance products in the State; (2) The plan provides minimum value, as
defined under §156.145; (3) The benefits are not excepted benefits, as established under
§146.145(b), and §148.220; and the benefits in the plan are from a plan year beginning after
December 31, 2013.
PRA Disclosure:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1174. The time required to complete this information collection is estimated to average 47 hours or 2,820 minutes
per response for States and .5 hours or 30 minutes per response for Stand Alone Dental Plans. This time includes
preparing, reviewing and submitting required documents. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

State Essential Health Benefits (EHB) Benchmark Plan –– Supporting Documentation and Justification

3. In accordance with §156.111(b)(2)(i), does the State’s proposed EHB-benchmark plan provide a scope
of benefits that are 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?
 Yes
 No
4. What plan was the basis for determining that the State’s proposed EHB-benchmark plan’s scope of
benefits are 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?

5. Briefly describe the methods, assumptions, and data used to determine that the State’s proposed EHBbenchmark plan provides a scope of benefits that are 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.1
•
•

Compare the benefits being offered, and
Compare the costs of the level of those benefits.

A copy of the Example of an Acceptable Methodology for Comparing Benefits of a State’s EHB-benchmark Plan Selection in Accordance
with 45 CFR 156.111(b)(2)(i) and (ii) is available on CCIIO’s Regulation and Guidance webpage at:
https://www.cms.gov/cciio/resources/regulations-and-guidance/index.html. The actuary’s response to Questions 5 and 8 may be the same or
different.

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State Essential Health Benefits (EHB) Benchmark Plan –– Supporting Documentation and Justification

Section 2: Limitation on Exceeding Generosity for §156.111(b)(2)(ii)
6. In accordance with §156.111(b)(2)(ii), does the State’s proposed EHB-benchmark plan definition
exceed the generosity of the most generous among a set of comparison plans, including 1) the State’s
EHB-benchmark plan used for the 2017 plan year, and 2) any of the State’s base-benchmark plan
options for the 2017 plan year described in §156.100(a)(1), supplemented as necessary under
§156.110?2
 Yes
 No
7. Which plan or plans were used as the basis to determine the most generous plan for this comparison?
_________________________________________________________________________
8. Briefly describe the methods, assumptions and data used to determine whether the State’s EHBbenchmark plan does not exceed the generosity of the most generous among a set of comparison plans:



Compare the benefits being offered, and
Compare the costs of the level of those benefits.

2

The Essential Health Benefits: List of the Largest Three Small Group Products by State for 2017 is available at
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Top3ListFinal-5-19-2015.pdf. States’ EHB-benchmark plans
used for the 2017 plan year are available at https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/Final-List-ofBMPs_4816.pdf.

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State Essential Health Benefits (EHB) Benchmark Plan –– Supporting Documentation and Justification

Section 3: Certification Language
45 CFR §156.111(e)(2) requires that a State selecting its EHB-benchmark plan must submit an
actuarial certification and an associated actuarial report from an actuary, who is a member of the
American Academy of Actuaries, in accordance with generally accepted actuarial principles and
methodologies that affirms:
(i)

That the State’s EHB-benchmark plan provides a scope of benefits 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 at §156.111(b)(2)(i) ; and

(ii)

That the State’s EHB-benchmark plan does not exceed the generosity of the most generous among the plans
listed in §156.111(b)(2)(ii)(A) and (B).

The analysis described in this document and supported in the actuarial report attached to this document was:
(i) conducted by a member of the American Academy of Actuaries, and
(ii) performed in accordance with generally accepted actuarial principles and methods, including complying with all
applicable Actuarial Standards of Practice (ASOP).
Actuary Signature:
Actuary Printed Name:
Date:

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