CMS approval of Washington State EHB‑benchmark plan change
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CMS approved Washington's application to change its Essential Health Benefits (EHB) benchmark plan, which will define covered benefits, limitations, and medical management requirements for non-grandfathered individual and small group plans and related programs starting for plan years on or after January 1, 2026.
CMS approves Washington's application to change its EHB-benchmark plan to expand coverage of human donor milk, hearing aids, and artificial insemination.
Coverage Criteria
The approval letter does not enumerate specific coverage exclusions. Instead, CMS approved Washington’s revised EHB‑benchmark plan, which will serve as the authoritative definition of covered benefits, limitations, and any exclusions for non‑grandfathered individual and small group health insurance coverage in Washington effective for plan years beginning January 1, 2026.
The letter does not identify particular services or conditions as not medically necessary. Medical necessity determinations and any explicit exclusions or limits will be governed by the terms of the approved EHB‑benchmark plan and applicable issuer policies for non‑grandfathered individual and small group coverage beginning January 1, 2026.
Provider Actions & Operational Notes
Prior authorization may be defined in the state's EHB‑benchmark
CMS notes that the state's EHB‑benchmark plan document includes benefits, limitations, and medical management requirements; any prior authorization requirements that apply to EHB‑covered services will be set forth in that benchmark plan and used by issuers.
No specific step therapy detailed in this approval
This approval letter does not specify any step therapy or other utilization management rules. Any step therapy requirements for EHB services would be contained in Washington’s EHB‑benchmark materials and issuer policies.
State submitted required § 156.111 documentation
Washington submitted the documentation required by § 156.111, including an actuarial certification and report and the new EHB‑benchmark plan document that reflects benefits, limitations, medical management requirements, and a schedule of benefits; CMS reviewed and found the application satisfied § 156.111 requirements.
- Actuarial certification and associated actuarial report from a qualified actuary.
- EHB‑benchmark plan document showing benefits, limitations, medical management requirements, and schedule of benefits.
- Other HHS‑specified documentation necessary to operationalize the benchmark plan.
Provider‑level prior authorization or denial triggers: not imposed by this letter
CMS approval of Washington’s EHB‑benchmark change is an administrative determination and does not itself impose provider‑level prior authorization, billing, or denial triggers; such requirements would derive from the benchmark plan and issuer policies, not from this approval letter.
Key Definitions
Background & Scope
This document is an administrative notice that CMS has approved Washington State’s application to change its EHB‑benchmark plan under 45 C.F.R. § 156.111. It does not provide clinical guidance on specific services or medical management; rather, it establishes the benchmark plan as the basis for defining Essential Health Benefits, benefits limits, and medical management requirements for affected plans starting January 1, 2026.
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