State Benchmark Plan Information

State Benchmark Plan Information

Beginning January 1, 2014, the Affordable Care Act (ACA, the healthcare reform bill) requires non-grandfathered (1) health plans to cover essential health benefits (EHB) set forth in the Act, which include items and services in the following ten benefit 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;
  10. pediatric services, including oral and vision care.

Subsequent regulations pertaining to the ACA allow for states to designate a health plan operating within their state to serve as the benchmark for EHBs. The benchmark plans represent the minimum benefits which any non-grandfathered individual and small group health plans eligible for purchase in a state, including those available through the state Exchange, must include. EHBs should be equal in scope to a typical employer health plan. If a state requires benefits beyond those outlined in the ACA, for example, coverage of hearing aids for children, states must defray the costs of that coverage.

Many benchmark plans do not include services in all of the required benefit categories. In those instances, regulations require that the state identify supplemental coverage. For habilitative services, states may define the services to be included in that category, or if they choose not to make that distinction, plans must provide parity with rehabilitative services.

Click here to view a state-by-state summary of audiology-related benefits in each benchmark plan

Additional resources on state benchmark plans:

(1) Note: Grandfathered plans are health plans that existed on March 23, 2010. These plans are required to provide the new benefits described in the health care reform bill but are exempt from many of the regulations. The plans are allowed to make routine changes without compromising their grandfathered status. Plans will lose their status if they significantly cut benefits or increase out-of-pocket spending for beneficiaries.