Appendix E - Benchmark Plans 2019 EHB Chart - Information Only

OMB Control Number: 0938-1174
Expiration Date: XX/XX/2021

Overview of State Documentation Requirements for EHB-benchmark Plans
The below chart provides an overview of the documents that a State needs to submit when selecting an EHB-benchmark Plan. These documents vary based on which option the State is using to select
for its EHB-benchmark Plan.

State Documentation Requirements

Confirmations: Complies with §156.111(a),
(b), and (c)
Actuarial certification and report:
1) Equal to, greater than, the scope of
benefits provided under a typical employer
plan
2) Does not exceed the generosity of the
most generous among certain plans
State’s EHB-benchmark plan document: 1)
Describes benefits and limits in accordance
with §156.111(e)(3)
2) Provides formulary drug list for the
State's EHB-benchmark Plan
EHB Summary Chart: Provides a summary
of the State's EHB-benchmark Plan

Option 2: Replace category or
Option 1: Select another
categories of benefits from
State's EHB-benchmark Plan [in
another State’s EHB-benchmark
accordance with
Plan [in accordance with §
§156.111(a)(1)]
156.111(a)(2)]
Required?
Required?

Option 3: Otherwise select a set of
benefits for the State’s EHBbenchmark Plan [in accordance with
§156.111(a)(3)]

Does this document require use of a
specific template?

Required?

Required?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

For the certification, yes;
the report, no

For

Yes

Yes

Yes

For the certification, yes;
the report, no

For

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

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. The time required to complete this information collection is estimated to average 47 hours or 2,820 minutes per response for States and
.5 hours or 30 minutes per response for Stand Alone Dental Plans. This time includes preparing, reviewing and submitting required documents. 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.