DraftWashington Office of the Insurance CommissionerPolicy N/A

Essential Health Benefit (EHB) Benchmark Plan Update — Coverage Criteria & Additions

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Describes Washington State's process to select and apply a new Essential Health Benefit benchmark plan affecting fully-insured commercial individual and small group markets if approved by CMS for plan year 2026.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyEssential Health Benefit (EHB) Benchmark Plan Update

Policy CodePolicy N/A

Change TypeAddition of donor human milk & hearing benefitpricing updates

Effective Date2026 (if approved by CMS)

Next Review DateN/A

Key ActionSubmit the EHB Benchmark Plan application to CMS following 45 CFR 156.111 with supporting actuarial documentation and medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

Washington is pursuing a new EHB Benchmark Plan to be effective for the 2026 plan year if approved by CMS.

Human donor milk and a hearing benefit are required additions to any new benchmark plan.

Pricing estimates for donor human milk, hearing aids/exams, artificial insemination, and IVF were provided as percent of total allowed costs.

PEBB was identified as the most generous eligible plan and effectively caps how rich benefits can be under federal generosity rules.

2026planned effective year

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DraftWashington Office of the Insurance CommissionerPolicy N/A

Essential Health Benefit (EHB) Benchmark Plan Update — Coverage Criteria & Additions

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Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyEssential Health Benefit (EHB) Benchmark Plan Update

Policy CodePolicy N/A

Change TypeAddition of donor human milk & hearing benefitpricing updates

Effective Date2026 (if approved by CMS)

Next Review DateN/A

Key ActionSubmit the EHB Benchmark Plan application to CMS following 45 CFR 156.111 with supporting actuarial documentation and medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

Washington is pursuing a new EHB Benchmark Plan to be effective for the 2026 plan year if approved by CMS.

Human donor milk and a hearing benefit are required additions to any new benchmark plan.

Pricing estimates for donor human milk, hearing aids/exams, artificial insemination, and IVF were provided as percent of total allowed costs.

PEBB was identified as the most generous eligible plan and effectively caps how rich benefits can be under federal generosity rules.

2026planned effective year

application deadline

0.01%–0.05%donor milk cost

0.04%–0.12%hearing aids cost

0.60%–1.10%IVF cost

0.11%–0.58%generosity room left

Coverage Criteria and Medical Necessity

Donor Human Milk Coverage Criteria

Covered when ALL of the following are met

Donor human milk inpatient medical necessity: Infant is medically or physically unable to receive maternal human milk or participate in chest feeding OR the parent is medically or physically unable to produce sufficient maternal human milk in quantity or caloric density

Inpatient use only; must meet additional clinical criteria such as low birth weight or gestational age <34 weeks (see statute 48.43.820)

Hearing Aids

Hearing exams and hearing aids are covered with the following limitation

Hearing aids coverage: Hearing examinations and hearing aids are a defined benefit for adults and childrenone per ear / 36 months

Frequency limit stated; additional medical necessity criteria and prior authorization requirements are not specified in this section

Fertility Services (IVF, AI)

Fertility services pricing and considerations

Fertility services considered: In vitro fertilization (IVF) and artificial insemination (AI) were evaluated for addition to the benchmark; IVF was priced as three cycles including evaluation, counseling, egg preservation, medication, extraction, fertilization, and related services, and AI was priced separatelyIVF 0.60%–1.10% of allowed costs (three cycles); AI 0.01%–0.02% of allowed costs

No explicit medical necessity criteria or coverage rules are provided here; IVF is unlikely to be added because its estimated cost may exceed remaining generosity test room; definition of a 'cycle' affects comparisons

The federal rules governing Essential Health Benefit (EHB) benchmark plans require CMS approval of any changes and prohibit benchmark plans from including lifetime or annual dollar limits or discriminatory benefits. States must follow the process in 45 CFR 156.111 when submitting an application (Washington targeted a May 2024 submission for a 2026 benchmark year), and failure to meet federal requirements could prevent CMS approval of proposed BMP changes.

Actuarial estimates indicate limited remaining room under the federal Generosity test after mandatory additions. Washington must add donor human milk and a hearing benefit, which together consume much of the available allowance; the analysis shows remaining room of approximately 0.11%–0.58%. Because In Vitro Fertilization (IVF) was priced at approximately 0.60%–1.10% (three cycles, including related services), the estimated cost for IVF likely exceeds the remaining generosity room and therefore is unlikely to be addable to the benchmark under current assumptions.

IVF was priced in this analysis as a bundle of three cycles (including evaluation, counseling, egg preservation, medications, extraction, fertilization, and related services) and estimated to add roughly 0.60%–1.10% to ongoing allowed costs. After required additions for donor human milk and hearing benefits, the analysis finds only 0.11%–0.58% of generosity test room remains; given that gap and the limitations of the Generosity test, the report concludes that IVF is unlikely to be added to the benchmark under the presented assumptions.

All cost and coverage analyses in this report are prepared under the explicit assumption that the Affordable Care Act (ACA) and related federal rules remain in effect with no material legal changes. The document discloses reliance on external data sources and states that material changes in federal or state law or regulation could materially affect both coverage feasibility and cost estimates, invalidating current conclusions.

The current benchmark identifies cardiac rehabilitative therapy visits as a covered service while PEBB (the most generous plan used for the Generosity comparison) does not cover those visits; this difference was noted in the benefit comparison and contributes to the overall PMPM and percent differences between the benchmark and PEBB. Specific service definitions and limits for cardiac rehab fall outside the cited chunks and should be referenced in the underlying plan documents when operationalizing coverage.

Coding, Frequency, and Code Lists

Fertility-related codes (not enumerated)mixed

affected codes

placeholder — document references pricing and services but does not list specific CPT/HCPCS codes in this section

Hearing aid frequency

Frequency limitOne hearing aid per ear every 36 months (one per ear/three years)

Covered itemsHearing exams and hearing aids for adults and children

Denial riskClaims exceeding the 36‑month frequency may be subject to denial or limit enforcement

Provider Actions, Authorization & Documentation

Note

EHBs set coverage, not administration; CMS approval required for BMP changes

EHBs define which benefits must be covered but do not govern how those benefits are administered; utilization management, cost sharing, or prior authorization requirements are not set by the EHB definition. Any change to the State's EHB Benchmark Plan must be approved by CMS and the BMP cannot include lifetime/annual dollar limits or discriminatory benefits.

EHBs set the 'what' (benefit scope) not the 'how' (administration or utilization rules).
CMS approval is required for any BMP change; BMPs may not include lifetime/annual dollar limits or discriminatory benefits.

Prior Authorization

No explicit prior-authorization code list for added benefits

The document does not list specific prior-authorization codes for added benefits; operational prior authorization requirements for donor human milk, hearing aids/exams, artificial insemination, and IVF are not specified here.

No explicit prior-authorization code list for the proposed added benefits is provided in this analysis.

Key Definitions

EHB / Benchmark Plan

DefinitionEssential Health Benefits (EHBs) are a set of benefits set by a state's benchmark plan (BMP) that all issuers are required to cover.

Scope vs administrationEHBs define what must be covered ('what') but do not govern benefit administration such as utilization management or cost sharing ('how').

Benchmark plan requirementA benchmark plan must offer benefits across 10 required benefit categories as defined by HHS regulations.

Donor human milk

DefinitionDonor human milk: medically necessary human milk supplied for inpatient use when the infant is medically or physically unable to receive maternal human milk or the parent cannot produce sufficient maternal milk in quantity or density.

Setting limitation

Background and Context

Donor human milk is defined as human milk supplied for inpatient use when the infant is medically or physically unable to receive maternal milk or the parent cannot produce sufficient maternal milk in quantity or caloric density. Coverage is limited to medically necessary inpatient use, and additional clinical criteria—such as low birth weight or gestational age under 34 weeks—apply; documentation must demonstrate the infant’s clinical need and that maternal milk is unavailable or insufficient.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyEssential Health Benefit (EHB) Benchmark Plan Update

Policy CodePolicy N/A

Change TypeAddition of donor human milk & hearing benefitpricing updates

Effective Date2026 (if approved by CMS)

Next Review DateN/A

Key ActionSubmit the EHB Benchmark Plan application to CMS following 45 CFR 156.111 with supporting actuarial documentation and medical necessity criteria.

SourceLink

On This Page

Coverage additions were evaluated for cost and generosity constraints, but administrative prior-authorization rules are not defined in these chunks.

Prior Authorization

Expect prior authorization for high‑cost IVF bundle (three‑cycle pricing)

IVF was priced as a bundle of three cycles including evaluation, counseling, egg preservation, drugs, extraction, fertilization, and related services; because IVF is high-cost (0.60%–1.10% of allowed costs), prior authorization to document medical necessity and define cycle counts is likely to be required though not explicitly specified here.

IVF pricing assumes three cycles and includes related evaluation, counseling, preservation, and procedural services.
Given IVF's estimated cost and bundle definition, expect prior authorization to be used to confirm medical necessity and scope per cycle.

Note

Federal EHB test steps are actuarial (no provider prior‑auth specified)

Federal EHB testing (Typicality and Generosity) requires actuarial comparisons of expected value at 100% AV between the proposed BMP and comparison plans; these federal test steps describe actuarial calculations but do not specify provider prior-authorization requirements.

Typicality and Generosity tests are actuarial comparisons of expected value at 100% actuarial value.
The tests address benefit comparability and generosity, not provider-level prior authorization processes.

Note

Utilization management and cost‑sharing are outside EHB specification

Benefit administration tools such as utilization management and cost‑sharing are not governed by EHB definitions; federal rules prohibit BMPs from including discriminatory benefits or lifetime/annual dollar limits, but carriers retain authority to apply utilization management within nondiscriminatory rules.

EHBs define benefit scope but not utilization management or cost sharing.
BMPs cannot include lifetime/annual limits or discriminatory benefit designs.

Step Therapy

No step‑therapy requirements specified for proposed benefits

No step‑therapy sequences or requirements are described for donor milk, hearing aids, artificial insemination, or IVF in this analysis.

The document does not define any step therapy protocols for the evaluated benefits.

Step Therapy

Step therapy not addressed in actuarial/disclosure sections

Step therapy is not addressed in the sections covering benefit additions and actuarial disclosures; providers should not assume any mandatory step sequences are defined here.

Disclosures and data reliance sections do not introduce step‑therapy requirements.
Absence of step‑therapy language means administrative sequences would need to be specified elsewhere if intended.

Documentation Required

Application must follow 45 CFR 156.111 and pass federal actuarial tests

The State's application to change the EHB Benchmark Plan must follow 45 CFR 156.111 and meet federal actuarial tests (Typicality and Generosity); Washington planned to submit the application in April 2024 for a 2026 effective year.

Follow the process at 45 CFR 156.111 and satisfy federal Typicality and Generosity tests.
Planned application submission: April 2024 (for 2026 benefit year).

Documentation Required

Document inpatient medical necessity for donor human milk with specified clinical criteria

Documentation for inpatient donor human milk claims must support medical necessity, including that the infant is medically or physically unable to receive maternal milk or the parent is unable to produce sufficient milk, and meet specified clinical criteria such as low birth weight or gestational age <34 weeks.

Document infant/parent inability to provide maternal milk (quantity or density) and applicable clinical criteria (e.g., low birth weight, <34‑week gestation).
Ensure claims indicate inpatient use, as the benefit is limited to inpatient medically necessary care.

Documentation Required

Document services and cycle counts to support IVF three‑cycle pricing

When billing IVF-related services, maintain documentation that supports the three‑cycle bundle assumptions — including evaluation, counseling, egg preservation, medication/drug utilization, extraction, fertilization, and the cycle counting used to price the benefit.

Record which services are included in each billed cycle and any drug or preservation services used.
Retain clinical records and counseling/evaluation notes to substantiate billed IVF bundle elements.

Documentation Required

Retain actuarial review — estimates rely on proprietary and external data sources

Actuarial estimates rely on Wakely's proprietary ACA dataset, Large Group data, stakeholder input, publications, and third‑party experts; users and administrators should retain actuarial expertise and review assumptions because results are sensitive to data reliance.

The analysis depends on external data sources and has not independently audited all underlying data.
Responsible actuaries are named and users should consult actuarial experts when interpreting results.

Denial Risk

CMS approval required — noncompliance with federal tests risks non‑approval

Any proposed BMP change requires CMS approval; failure to satisfy federal regulations (Typicality, Generosity, or other CMS criteria) could result in non‑approval and prevent the change from being adopted.

CMS approval is mandatory for BMP changes.
Not meeting Typicality or Generosity test results may block adoption of proposed additions.

Denial Risk

Donor human milk coverage limited to inpatient medically necessary use — denials possible if criteria not met

Coverage for donor human milk is expressly limited to medically necessary inpatient use and must meet listed clinical criteria; services not meeting those inpatient clinical criteria may be denied.

Benefit applies only for inpatient medically necessary use when infant/parent meet criteria (e.g., low birth weight, <34‑week gestation).
Claims for outpatient or non‑criterial situations may be subject to denial.

Denial Risk

Hearing aids limited to one per ear every 36 months — excess claims may be denied

Hearing aids are limited to one per ear every three years; claims seeking replacement or additional devices outside this frequency may be denied or limited under the benefit.

Frequency limit: one hearing aid per ear every 36 months.
Claims exceeding the frequency limit may be subject to denial or benefit limitation.

Denial Risk

Regulatory or statutory changes may materially alter coverage feasibility and cost estimates

These analyses assume the Affordable Care Act remains in effect; material state or federal law or regulatory changes could materially affect coverage decisions, cost estimates, and the ability to adopt proposed BMP changes.

Subsequent material legal or regulatory changes may invalidate current assumptions and estimates.
Users should monitor regulatory developments that could change BMP feasibility or costs.

Billing Rule

Preserve benefit‑administration and actuarial implementation tools for operational prior‑auth and claims handling

Providers and administrators should retain all actuarial documentation, utilization‑management rules, and benefit‑administration tools used to implement the BMP, since EHBs do not prescribe administration and these materials will govern operational prior‑authorization and claim handling.

EHBs do not define utilization management; benefit administration tools must be prepared and retained locally.
Actuarial and implementation materials are necessary to support operational decisions and potential CMS review.

Coverage limited to inpatient use.

Clinical criteriaMust meet clinical criteria such as low birth weight or gestational age <34 weeks (and other listed indications).

IVF cycle

Cycle definitionAn IVF 'cycle' is the priced unit used for IVF (document priced three cycles) and may include evaluation, counseling, egg preservation, medication, extraction, fertilization, and related services.

Pricing contextIVF was priced as three cycles for actuarial comparison; most cost is from fertility drugs and extraction; preservation and fertilization contribute less.

Comparability noteHow a 'cycle' is defined can materially alter cost comparisons and generosity-test results; definition should be specified when evaluating pricing or coverage decisions.