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IL Department of Insurance Recommends Essential Health Benefit (EHB) Benchmark for Plan Year 2017

SPRINGFIELD – July 2, 2015.  The Illinois Department of Insurance has recommended the BlueCross BlueShield of Illinois "Blue PPO Gold 011" small group plan, supplemented with the All Kids pediatric dental package and the federal definition for habilitative services and devices, to the U.S. Department of Health and Human Services (HHS) as the new Essential Health Benefit (EHB) benchmark beginning Plan Year 2017. This selection meets the Department's goals of recommending an EHB benchmark that provides comprehensive coverage, would not be expected to increase the cost of coverage, and minimizes market disruption.  This recommendation preserves the benefits offered under the current EHB benchmark without reducing the coverage in any of the 10 EHB categories. 

Beginning in 2014, the federal Affordable Care Act (ACA) required health plans sold in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, to offer a comprehensive package of items and services, known as EHBs.  To set a standard for the comprehensive package of benefits that health plans must cover, the ACA created 10 EHB categories:

  1. Ambulatory care;
  2. Emergency services;
  3. Hospitalization;
  4. Pregnancy, 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.

Additionally, HHS set specific guidelines to establish the value of coverage within each of the 10 EHB categories by requiring an EHB benchmark in each state that is representative of a typical small employer plan.  As a result, most plans sold in the individual and small group markets must offer coverage that is of equal or greater value to the coverage offered in the EHB benchmark in the 10 EHB categories. 

The federal government provides specific plans for the state to choose between when determining the EHB benchmark.  Previously, HHS let states choose between plans offered in their state in the first quarter of 2012 to determine the EHB benchmark beginning in Plan Year 2014.  Now, HHS is letting states choose between plans that were offered in their states in the first quarter of 2014 to determine the new EHB benchmark beginning in Plan Year 2017. 

To determine the EHB benchmark, HHS allows states to choose between 10 base-benchmark plans:

  • The three largest small group plans by enrollment in the three largest small group insurance products by enrollment in the state's small group market;
  • The three largest state employee health plans by enrollment in the state;
  • The three largest federal employee health plans by enrollment; or
  • The largest insured commercial non-Medicaid health maintenance organization (HMO) plan in the state.

If the base-benchmark plan does not include any of the 10 EHB categories, the missing EHB category must be supplemented with coverage from a different plan.  The Children's Health Insurance Plan (known as All Kids in Illinois) or the largest federal employee dental or vision plan by enrollment may be used as the EHB benchmark for pediatric vision or pediatric dental services.  Also, the new federal definition for habilitative services may be used as the EHB benchmark for habilitative services. 

Public comments will be accepted by the federal government in the summer of 2015 before the new EHB benchmark is finalized.  The federal government has not yet released the date the public comment period will begin.

Additional information about the EHB benchmark selection process is available at Essential Health Benefits - Basic Facts and State Options and additional information about EHB coverage in health plans is available at https://getcovered.illinois.gov/Fact%20Sheets/GCI_EssentialBenefits.pdf.