Pennsylvania's Essential Health Benefits Benchmark Plan
Public Comment Period
The Patient Protection and Affordable Care Act of 2010 (ACA) outlines coverage requirements for health insurance policies. The minimum coverage categories are established as ten Essential Health Benefits (EHB) which include:
- Ambulatory Patient Services
- Emergency Services
- Hospitalization
- Maternity and Newborn Care
- Mental Health and Substance Use Disorder Services and Behavioral Health Treatment
- Prescription Drugs
- Rehabilitative and Habilitative Services and Devices
- Laboratory Services
- Preventive and Wellness Services and Chronic Disease Management
- Pediatric Services (including oral and vision care)
Under the ACA, the federal Department of Health and Human Services (HHS) issued regulations that define the EHBs based on State-specific EHB Benchmark plans. This plan sets the minimum coverage requirements a health insurance plan must offer to be considered a Qualified Health Plan under the ACA. States that did not actively select a benchmark plan from a set of plan options by 2014 defaulted to the largest small group plan; many states have updated their EHB Benchmark Plan since their original selection. Most recently, Pennsylvania recommended to HHS that the default plan option serve as the benchmark plan beginning on January 1, 2017. The current benchmark plan for Pennsylvania is the
Gold Premier HMO by Keystone Health Plan East*.
The 2019 Notice of Benefit and Payment Parameters (NBPP) reformed the process states use to update the EHB Benchmark Plan by amending the federal regulation governing the process (45 CFR § 156.111). If a State chooses to update its EHB Benchmark Plan, the State is required to select from three prescribed options:
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Selecting the EHB-benchmark plan that another State used for the 2017 plan year;
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Replacing one or more categories of EHBs in a State's 2017 benchmark with the same category from another State's 2017 EHB benchmark; or
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Otherwise selecting a set of benefits that would become the State's EHB benchmark.
The State's selection must undergo an independent actuarial certification to verify that the proposed EHB Benchmark Plan update complies with the regulatory standards. Further, the State must conduct a public comment period on the application package to be submitted to the Centers for Medicaid and Medicare Services (CMS) for CMS to evaluate and approve the updated EHB Benchmark Plan. All required documentation must be submitted to CMS by the first Wednesday in May, two years prior to the anticipated effective date of the updated EHB Benchmark Plan.
Pennsylvania Bulletin Notice 2023-14 published on July 29, 2023, established a public comment period as the Insurance Department explores the potential benefits of updating the commonwealth's EHB Benchmark Plan. The Department received 50 comments from individuals, legislators, and stakeholder groups. This public comment period was not required by CMS to update the EHB Benchmark Plan, rather it was provided by the Department to allow an opportunity for input into the process. The below comments were received as a result of this exploratory public comment period:
*This resource is provided by The Centers for Medicare & Medicaid Services (CMS) and is publically available at https://www.cms.gov/marketplace/resources/data/essential-health-benefits.