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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyMississippi EHB Benchmark Plan Coverage | OpenPaye…
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    CurrentMississippi Insurance DepartmentPolicy N/A

    Guide to Reviewing Essential Health Benefits Benchmark Plans

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    This guide explains how issuers should review and design plans substantially equal to EHB-benchmark plans, including required coverage limitations, excluded benefits, state mandates, parity, prescription drugs, habilitative services, and preventive services. It applies to health plans using EHB-benchmark plan designs for plan years beginning on or after January 1, 2014.

    Policy Summary
    PayerMississippi Insurance Department
    PolicyGuide to Reviewing Essential Health Benefits Benchmark Plans
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDo not apply annual or lifetime dollar limits to essential health benefits; convert them only to actuarially equivalent treatment or service limits.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2012EHB-benchmark plan design reference year
    2014Additional requirements begin
    4Excluded benefit categories
    2 yearsHabilitative transition

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    1+Minimum drugs per USP category/class

    Essential Health Benefits Coverage Requirements

    Post-2014 benchmark plan design

    When designing a plan substantially equal to an EHB-benchmark plan for plan years beginning January 1, 2014 or later, apply requirements and limitations that may supplement or override the 2012 benchmark design.

    Post-2014 EHB plan design: The issuer must account for applicable requirements and limitations beyond the 2012 EHB-benchmark plan design.Plan years beginning on or after January 1, 2014

    These requirements may affect plan benefits, coverage, and limitations.

    Dollar-limit treatment

    Annual and lifetime dollar limits cannot be applied to essential health benefits.

    Permitted limit treatment: A plan may avoid applying prohibited dollar limits by converting them to actuarially equivalent treatment or service limits.Actuarially equivalent treatment or service limits

    Annual and lifetime dollar limits may not be applied to EHB.

    Habilitative services

    When the benchmark plan has no habilitative coverage and the state does not define habilitative benefits:

    Habilitative services transition: The issuer determines which habilitative services to offer as part of a transitional policy.Two-year transitional policy

    This applies only when the benchmark plan does not cover any habilitative services and the state does not define those benefits.

    Coverage category limits

    Except for coverage of pediatric services, a plan may not exclude an enrollee from an entire EHB category.

    EHB category availability: The plan must make each EHB category available to enrollees and may not categorically exclude dependent children from maternity and newborn coverage.No exclusion of an entire EHB category

    Coverage for pediatric services is the stated exception.

    State-required benefit classification

    For purposes of determining EHB, classify state requirements according to the type of mandate involved.

    EHB state-mandate classification: Count requirements that a health plan cover specific care, treatment, or services as state-required benefits.

    Do not count provider mandates, dependent mandates, or state antidiscrimination requirements concerning the service-delivery method. Examples include provider reimbursement mandates, dependent-definition or dependent-coverage mandates, and telemedicine-related service-delivery requirements.

    Mental health parity

    EHB plans must comply with MHPAEA standards.

    Mental health parity: The plan must comply with the standards implemented under the Mental Health Parity and Addiction Equity Act of 2008.MHPAEA standards

    Noncompliance by the displayed benchmark plan does not eliminate the EHB plan's obligation.

    Prescription drug coverage

    Prescription drug coverage must meet the greater-of standard for USP categories and classes.

    Prescription drug category and class coverage: The plan must offer the greater of one drug in every USP category and class or the number of drugs in each USP category and class offered by the EHB-benchmark plan. If the benchmark plan has no coverage in a USP category or class, the plan must offer one drug in that category or class.Greater of 1 drug per USP category and class or the benchmark-plan count

    A category may be listed without a USP class when some drugs in that category lack an assigned class.

    Preventive services

    EHB plans must comply with 45 CFR 147.130 preventive-services requirements.

    Preventive services: The plan must provide preventive services required under 45 CFR 147.130, regardless of whether those services appear in the displayed benchmark plan.45 CFR 147.130

    The benchmark plan's omission does not remove the federal preventive-services obligation.

    Excluded from essential health benefits are routine non-pediatric dental services, routine nonpediatric eye examination services, long-term or custodial nursing home care benefits, and nonmedically necessary orthodontia—even when an EHB-benchmark plan covers them.

    Abortion services are not required as part of essential health benefits. An issuer may choose to cover these services, and applicable state law may prohibit or require coverage.

    Nonmedically necessary orthodontia is excluded from essential health benefits, including when it is covered by an EHB-benchmark plan.

    Operational Compliance Requirements

    Denial Risk

    Improper Dollar Limits on EHB

    Do not apply annual or lifetime dollar limits to essential health benefits (EHB), even when those limits appear in the displayed EHB-benchmark plan. Such limits may be converted to actuarially equivalent treatment or service limits under 45 CFR 147.126.

    • Treat EHB dollar limits as prohibited annual or lifetime limits.
    • Use actuarially equivalent treatment or service limits only when permitted.
    Billing Rule

    Excluded Benefits

    Apply the EHB exclusions required by 45 CFR 156.115 even when the displayed benchmark plan covers the benefit. Abortion services are not required as EHB under ACA section 1303(b)(1)(A), although an issuer may choose to cover them and state law may prohibit or require coverage.

    EHB-Benchmark Plan Context

    EHB-benchmark plans are based on 2012 plan designs and may not reflect requirements applicable to plan years beginning on or after January 1, 2014. Issuers must account for federal requirements that supplement or override benchmark-plan limitations when designing substantially equal plans.

    Key EHB Terms

    State-required benefits
    DefinitionRequirements that a health plan cover specific care, treatment, or services.
    Provider mandatesRequirements to reimburse specific health care professionals who render a covered service within their scope of practice are not state-required benefits for EHB purposes.
    Dependent mandatesRequirements to define dependents in a specific manner or cover dependents under certain circumstances are not state-required benefits for EHB purposes.
    Service-delivery requirementsState antidiscrimination requirements relating to the method of service delivery, such as telemedicine, are not state-required benefits for EHB purposes.
    Excluded benefits
    DefinitionBenefits that may appear in an EHB-benchmark plan but are not included within EHB under 45 CFR 156.115.
    Policy Summary
    PayerMississippi Insurance Department
    PolicyGuide to Reviewing Essential Health Benefits Benchmark Plans
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDo not apply annual or lifetime dollar limits to essential health benefits; convert them only to actuarially equivalent treatment or service limits.
    SourceLink
    On This Page
    Essential Health Benefits Coverage RequirementsOperational Compliance RequirementsEHB-Benchmark Plan ContextKey EHB Terms
    • Exclude routine non-pediatric dental services.
    • Exclude routine nonpediatric eye exam services.
    • Exclude long-term or custodial nursing home care benefits.
    • Exclude nonmedically necessary orthodontia.
    • Do not treat abortion coverage as required EHB coverage; evaluate applicable issuer and state-law requirements.
    Denial Risk

    Entire EHB Category Exclusion

    Do not exclude an enrollee from coverage in an entire EHB category, regardless of whether the limitation appears in the EHB-benchmark plan. The exception is coverage for pediatric services under 45 CFR 156.115(a)(2).

    • Maintain access across every EHB category.
    • Do not exclude dependent children from an entire category, such as maternity and newborn coverage.
    • Apply the pediatric-services exception only as permitted.
    Documentation Required

    Mental Health Parity Compliance

    Apply the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) standards to EHB plans, even when the displayed EHB-benchmark plan does not appear to comply. Benchmark-plan displays do not override the requirements implemented under 45 CFR 156.115(a)(3).

    • Review mental health and substance use disorder benefits for MHPAEA compliance.
    • Do not rely solely on the limitations or displays in the benchmark plan.
    Prior Authorization

    Preventive-Services Compliance

    Provide preventive services in compliance with 45 CFR 147.130, even when the displayed EHB-benchmark plan does not include all required services. EHB plans must comply with that section under 45 CFR 156.115(a)(4).

    • Compare preventive-service coverage against the requirements of 45 CFR 147.130.
    • Add or administer required preventive services regardless of omissions in the benchmark-plan display.
    Dental servicesRoutine non-pediatric dental services are excluded from EHB.
    Eye examination servicesRoutine nonpediatric eye exam services are excluded from EHB.
    Nursing home careLong-term or custodial nursing home care benefits are excluded from EHB.
    OrthodontiaNonmedically necessary orthodontia is excluded from EHB.
    Abortion servicesA health plan is not required to cover abortion services as part of EHB; an issuer may choose to cover them, and state law may prohibit or require coverage.