Form CMS-10448 State Annual Report

State Annual Report on State-Required Benefits

OMB Control Number: 09381174
Expiration Date: 06/01/2021

OVERVIEW & INSTRUCTIONS
Overview

Under 45 CFR 156.111(d), a state must notify HHS of any state-required benefits that are in addition to the essential health benefits (EHB) identified under §155.170(a)(3) in
accordance with §156.111(f), which specifies the types of information states are required to submit to HHS by the annual submission deadline in a form and manner specified
by HHS. If the state does not notify HHS of its state-required benefits that are in addition to EHB described under §155.170(a)(3) in accordance with paragraph §156.111(f),
HHS will determine which benefits are in addition to EHB for the applicable plan year in the state. We intend to post state submissions of their state-required benefits (Tab 3)
on the CMS website prior to the end of the plan year during which the annual reporting takes place.

Contact_Information Tab

Complete your state's primary and secondary contact information in this tab of the worksheet. Contact information (Tab 2) will not be posted on the CMS website.

State-Required Benefits Tab

Complete all fields for this tab (Columns A-M) for all state-required benefits. For purposes of determining EHB, state-required benefits (or mandates) are considered to
include only requirements 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.

DATA DICTIONARY
Column Letter

Header

Description/Example
The short hand name of the benefit, for example "applied behavioral analysis (ABA) therapy." If
there are multiple state-required benefits mandated in a single state action, list each distinct
benefit in a separate row.

A

Name of required benefit(s)

B

All relevant language to describe the exact coverage required. For example:
"Any individual market health benefit plan offered on or after January 1, 2022, shall provide
Precise benefit or set of benefits and precise coverage coverage for behavioral health treatment of autism spectrum disorder at zero cost-sharing."
parameters, including any exclusions
If multiple state actions were taken to mandate the benefit, only include in this field the final
and controlling language describing the coverage requirement.

C

Market applicability and, if applicable, product type
applicability

Be as specific as possible. Examples include: individual and large group; individual and small
group; individual market; individual market PPOs; individual market HMOs; small group;
individual market HDHPs; grandfathered individual, etc.
The state authority requiring the benefit (e.g., statute, regulation, guidance, bulletin, etc.) and
body (department of insurance, governor, legislature etc.) responsible for it. Be specific. Include
any and all state action. This should be an exhaustive list.

D

E

F

Type of state action to require coverage of the benefit
(any and all state action) and type of body taking the For example, if the state-required benefit was mandated broadly in statute, then published in
state action
an emergency regulation to implement the requirement and provide additional detailed
requirements, and finalized in a permanent regulation, the state should list all three of these
state actions (statute, emergency regulation, and permanent regulation) and the responsible
parties (legislature, department of insurance).
URL for final text of state action, if available

Best active URL to use to access the state action and read it in full. If there were multiple state
actions, list all relevant URLs and indicate to which state action they belong. If an active URL is
not readily available, please indicate "N/A".

Year of enactment

Year the mandate was enacted (signed into law), published, issued as a final action, etc. If there
were multiple state actions, list all relevant enactment dates and indicate to which state action
they belong.

G

Year amended (any and all amendments)

Year mandate was amended (or for a regulation or bulletin, year mandate was changed or
modified). Include any and all amendments, changes, or modifications. If there were multiple
state actions, list all amendment years and indicate to which state action they belong. Note
"N/A" if this doesn't apply.

H

Year applicable market must begin complying
with required benefit

Year QHP issuers must begin complying with the state-required benefit. If there are multiple or
staggered effective dates for the state-required benefit, list each one and concisely explain
what QHP issuers are expected to comply with beginning on each date.

I

Year repealed, rescinded, or overturned

Year the state-required benefit was repealed, rescinded, or overturned. If the state-required
benefit has never been repealed, rescinded, or overturned, indicate "N/A".

Exact citation to the statute, law, and/or regulation (with a pincite to exact section). If guidance,
bulletin, or other state action, include the specific name of the document, body that issued it, a
pincite to the relevant portion of the state action, and where the state action can be located
(such as the department of insurance website). Be as specific as possible.
J

Citation

For example, a citation to a state statute should include (1) the state abbreviation (2) the title
number (3) the abbreviation of the code used (4) the section number containing the statute
and (5) the year of the code.
If there are multiple state actions, list all relevant citations and indicate to which state action
they belong.

K

L

M

Is the state-required benefit in addition to EHB and
subject to defrayal in accordance with §155.170?

Yes/No. To make this determination, states should refer to applicable implementing regulations
(such as §155.170), preamble, and CMS guidance.

If not in addition to EHB and not subject to
defrayal describe the basis for the state’s
determination

Concise explanation describing why the state-required benefit is not subject to defrayal. Cite to
any applicable federal standards for determining whether a state-required benefit is not in
addition to EHB and does not require defrayal. For example, a state could explain that a staterequired benefit is not in addition to EHB and does not require defrayal because the staterequired benefit was enacted on or before December 31, 2011. State should note "N/A" if this
doesn't apply.

Date that this report was last updated by state
(MM/DD/YY)

Date that the state last updated the report. If this is the first time the state is submitting a
report to HHS, indicate "first time reporting". If the state submitted a report on May 1, 2021,
did not submit a report in plan year 2022, and is submitting a report on May 1, 2023, the state
should indicate in its plan year 2023 submission that the state last updated the report on
"05/01/2021."

PRA Disclosure Statement
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 (Expires 06/01/2021). The time required to complete this information collection is estimated to average 30
hours or 1,800 minutes in the first year and 13 hours or 780 minutes annually in the second and third year for states to report state mandates. 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.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note
that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Valisha Jackson at [email protected].

State Contact Information

Points of Contact for the State-Required Benefits

Primary

OMB Control Number: 0938-1174
Expiration Date: 06/01/2021

Secondary

State
Name
Agency
Phone Number
Email

PRA Disclosure Statement
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 (Expires 06/01/2021). The time required to complete this
information collection is estimated to average 30 hours or 1,800 minutes in the first year and 13 hours or 780 minutes annually in the second and
third year for states to report state mandates. 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.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Valisha Jackson at [email protected].

State-Required Benefits
A
Name of required
benefit(s)

B
C
Precise benefit or Market applicability
set of benefits and and, if applicable,
precise coverage
product type
parameters,
applicability
including any
exclusions

Any individual
market health
benefit plan offered
on or after January
This row is meant as 1, 2010, shall
an example only:
provide coverage for
Applied Behavioral behavioral health
Analysis (ABA)
treatment of autism Individual and small
Therapy
spectrum disorder. group market

D
E
F
G
H
Type of state action URL for final text of Year of enactment Year amended (any
Year applicable
to require coverage
state action, if
(YYYY)
and all
market must begin
of the benefit (any
available
amendments)
complying with
and all state action)
(YYYY)
required benefit
and type of body
(YYYY)
taking the state
action

Statute (legislature);
emergency
regulation
(department of
insurance); final
regulation
(department of
insurance)

Statute URL:
[website]
Emergency
regulation URL:
[website]

I
Year repealed,
rescinded, or
overturned
(YYYY)

OMB Control Number: 0938-1174
Expiration Date: 06/01/2021

J
Citation

K
L
M
Is the state required If not in addition to Date that this report
benefit in addition EHB and not subject was last updated by
to EHB and subject to defrayal describe
state
to defrayal in
the basis for the
(MM/DD/YY)
accordance with
state’s
§155.170?
determination:

Statute: [State Abbreviation] Code.
Ann §2503.04 (2009)
Statute: 2009

Emergency regulation: State Insurance
Emergency Regulation 14-E-06
Concerning Applied Behavioral
Analysis Therapy (Mar. 20, 2009)

Emergency
regulation: 2009

Final regulation URL: Final regulation:
[website]
2009

N/A

2010 N/A

Final regulation: [State Abbreviation]
Admin. Code tit. 40, § 98.92 (2009)

No

Enacted prior to
12/31/11

first time reporting

PRA Disclosure Statement
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 (Expires
06/01/2021). The time required to complete this information collection is estimated to average 30 hours or 1,800 minutes in the first year and 13 hours or 780 minutes annually in the second and third year for states to report state mandates. 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.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved
under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Valisha Jackson at [email protected].