CMS-10448 EHB Benchmark Plan Certificate

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

Clear Form

OMB No. 0938-1174

Expires: XX/XX/20XX

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 the scope of benefits
provided under a typical employer plan as defined at § 156.111(b)(2)(i) (supplemented by the State as necessary to
provide coverage within each EHB category at § 156.110(a)).
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: TYPICAL EMPLOYER PLANS DETERMINATION FOR § 156.111(b)(2)(i)
1. 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 the scope of benefits provided under a typical employer plan as defined at § 156.111(b)(2)(i)
(supplemented by the State as necessary to provide coverage within each EHB category at § 156.110(a))?
Yes

No

2. The State's proposed EHB-benchmark plan must provide a scope of benefits that is equal to the scope benefits of a
typical employer plan in the State. The scope of benefits in a typical employer plan in a State is any scope of benefits that
is as or more generous than the scope of benefits in the least generous plan (supplemented by the State as necessary to
provide coverage within each EHB category at § 156.110(a)), and as or less generous than the scope of benefits in the
most generous plan in the State (supplemented by the State as necessary to provide coverage within each EHB
category at § 156.110(a)), among the following the plans at § 156.111(b)(2)(ii)(A) and (B). What plans did the state
identify as the least and most generous plans among the plans at § 156.111(b)(2)(ii)(A) and (B)?

3. 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 the scope of benefits provided under a typical employer plan (or
greater than the scope of benefits provided under a typical employer plan, to the extent any supplementation is required
to provide coverage within each EHB category at § 156.111(a)).

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OMB control number. The valid OMB control number for this information collection is 0938-1174, expiration date XX/XX/20XX. The time required to complete
this information collection is estimated to average 205 hours per response for States. 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 Ken Buerger at [email protected].
APPENDIX B: EHB-BENCHMARK PLAN ACTUARIAL CERTIFICATE TEMPLATE

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
SECTION 2: 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 that the State’s EHB-benchmark
plan provides a scope of benefits that is equal to the scope of benefits provided under a typical employer plan as
defined at § 156.111(b)(2)(ii) (supplemented by the State as necessary to provide coverage within each EHB category
at § 156.110(a)).
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

APPENDIX B: EHB-BENCHMARK PLAN ACTUARIAL CERTIFICATE TEMPLATE

Date

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