CMS-10448 EHB Benchmark Plan Certification

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-1174

Expires: 06/01/2021

APPENDIX B: ESSENTIAL HEALTH BENEFITS (EHB)-BENCHMARK PLAN
ACTUARIAL CERTIFICATE TEMPLATE
Instructions for Completing Appendix B:
Under §156.111(e)(2), States must submit an actuarial certification as part of the EHB-benchmark selection process
affirming that the State’s 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 §156.111(a), the scope of benefits provided under a typical
employer plan as defined at §156.111(b)(2)(i); and
does not exceed the generosity of the most generous among plans listed at §156.111(b)(2)(ii)(A) and (B).

States must complete all fields of this actuarial certification. CMS will consider any partial or blank fields as incomplete.
The actuarial report associated with this certification must be submitted as an attachment. Actuarial reports should be
uploaded in a format that prevents further editing after submission. For example, States can scan copies of the Actuarial
Report or convert documents into a PDF format to upload

SECTION 1: BACKGROUND INFORMATION
State

1. Which EHB-benchmark plan option (at 45 CFR §156.111(a)) is the State using to make changes to its EHBbenchmark plan? (Only provide one selection)
(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 2: 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? (Only provide one selection)
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.
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

APPENDIX B: EHB-BENCHMARK PLAN ACTUARIAL CERTIFICATE TEMPLATE

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-1174

Expires: 06/01/2021

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 EHB-benchmark 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.

SECTION 3: LIMITATION ON EXCEEDING GENEROSITY FOR §156.111(b)(2)(i)
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 EHB-benchmark 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.

1
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-andguidance/index.html. The actuary's response to Questions 4 and 8 may be the same or different.
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-of-BMPs_4816.pdf.
APPENDIX B: EHB-BENCHMARK PLAN ACTUARIAL CERTIFICATE TEMPLATE

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-1174

Expires: 06/01/2021

SECTION 4: 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)

(ii)

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
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)
(ii)

conducted by a member of the American Academy of Actuaries, and
performed in accordance with generally accepted actuarial principles and methods, including complying with
all applicable Actuarial Standards of Practice (ASOP).

Name of Actuary Completing Form

Actuary Signature

Date

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 47 hours or 2,820 minutes per
response for States. For Form 1, the estimate is 4 hours. For Form 2, the estimate is 19 hours. For Form 3, the estimate is 12
hours. For Form 4, the estimate is 12 hours. 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].

APPENDIX B: EHB-BENCHMARK PLAN ACTUARIAL CERTIFICATE TEMPLATE

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