Form CMS-10488 EHB Confirmation Template

Confirmations on the State
EHB-benchmark Plan

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

Instructions: All fields on this template are required to be completed. 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. Under Section D, please complete the "Explanation" column with sentences describing how the State is complying with the specific
requirement; single word responses such as Yes, No, or N/A are not sufficient responses.

SECTION A
Points of Contact for the State's EHB- benchmark Plan Selection

Primary

Secondary

Name
Agency
Phone Number
Email

SECTION B
State's Selections

EHB-Benchmark Plan Selection Options
State
Under which option of 45 CFR 156.111(a), is the State selecting its new EHBbenchmark Plan?
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?

SECTION C

EHB Category Criteria for a State EHB-benchmark Plan at 45 CFR 156.111

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

Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health
treatment
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?
Rehabilitative and habilitative services and devices
Laboratory services
Preventative, wellness, and chronic disease management
Pediatric services, including oral and vision care
* 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.

SECTION D
Under Section D, please complete the "Explanation" column with sentences describing how the State is complying with the specific requirement;
single word responses such as Yes, No, or N/A are not sufficient responses.
EHB-Benchmark Plan Requirements
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
provided under a typical employer plan as defined at §156.111(b)(2)(i) and in
accordance with §156.111(e)(2)?
Does the State's EHB-benchmark Plan 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)? Please provide the public
notice dates and applicable website address in the "Explanation" column.
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 and in accordance with §156.111(b)(2)(v)?
Is there any additional information CMS should know?

State's Confirmations

Explanation

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