Form CMS-10488 EHB Confirmation Template

Confirmations on the State EHB-Benchmark Plan

OMB Control Number: 0938-1174
Expiration Date: XX/XX/20XX

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

Name
Agency
Phone Number
Email

SECTION B
EHB-Benchmark Plan Selection Options

State's Selections

State
For what plan year is the State selecting its new EHB-benchmark Plan to begin
applying?

SECTION C
EHB Category Criteria for a State EHB-benchmark Plan at 45 CFR 156.111
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 changing its prescription drug EHB, 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

Does the State's EHB-benchmark Plan
cover the EHB category?

Secondary

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 EHBbenchmark plan.

SECTION D
Under Section D, please complete the "Explanation" column with complete sentences
describing how the State is complying with the specific requirement.
EHB-Benchmark Plan Requirements

State's Confirmations

Explanation

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 the scope of benefits provided under a
typical employer plan as defined and established at § 156.111(b)(2)(ii) (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 §
156.110(a))?
Has an actuary, who is a member of the American Academy of Actuaries, in
accordance with generally accepted actuarial principles and methodologies, affirmed
in accordance with § 156.111(e)(2) that the State's new EHB-benchmark plan provides
a scope of benefits that is equal to the scope of benefits provided under a typical
employer plan as defined and established at § 156.111(b)(2)(ii) (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 §
156.110(a))?
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 non-pediatric eye exam services, longterm/custodial nursing home care benefits, or non-medically necessary 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?
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 information collection included in this package reflects the time and effort for states to select
a new EHB-benchmark plan. The time required to complete this information collection is estimated to average less than 205 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection, pursuant to 45
C.F.R. 156.111, requires states who wish to modify their benchmark plans to respond to this ICR. All information collected will be kept private in accordance with
regulations at 45 C.F.R. 155.260, Privacy and Security of Personally Identifiable Information. 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, Mail Stop c4-26-05, Baltimore, Maryland 21244-1850, Attention: Information
Collections Clearance Officer, or email Ken Buerger at [email protected].