1. (a) The purpose of this part is to comply with requirements issued by the United States Department of Health and Human Services for states to select a benchmark health plan before September 30, 2012, to serve as the standard for providing essential health benefits (EHB) in nongrandfathered health plans offered through the exchange operating in the state as well as to nongrandfathered plans offered in the individual and small group markets outside the exchange in the state.

2. (b)

   1. (1) Section 1302(b) of the Affordable Care Act directs the Secretary of the United States Department of Health and Human Services to define EHB for health plans subject to the Affordable Care Act.
   2. (2) Under the Affordable Care Act, nongrandfathered plans in individual and small group markets both inside and outside of the exchanges must provide EHB beginning in 2014.

   3. (3) Section 1302(b) of the Affordable Care Act provides that EHB include items and services within the following ten (10) benefit categories:

      1. (A) Ambulatory patient services;
      2. (B) Emergency services;
      3. (C) Hospitalization;
      4. (D) Maternity and newborn care;
      5. (E) Mental health and substance use disorder services, including behavioral health treatment;
      6. (F) Prescription drugs;
      7. (G) Rehabilitative and habilitative services and devices;
      8. (H) Laboratory services;
      9. (I) Prevent wellness services and chronic disease management; and
      10. (J) Pediatric services, including oral and vision care.
   4. (4) Section 1302(b)(2) requires that the Secretary of the United States Department of Health and Human Services provide that the scope of EHB be equal to benefits provided under a typical employer plan.

3. (c)

   1. (1)

      1. (A) On December 16, 2011, the United States Department of Health and Human Services issued "Essential Health Benefits: HHS Informational Bulletin", and thereafter on January 25, 2012, "Essential Health Benefits: Illustrative List of the Largest Three Small Group Products by State".
      2. (B) These bulletins are the Secretary of the United States Department of Health and Human Services’ implementation of Section 1302(b) of the Affordable Care Act.

   2. (2)

      1. (A) Under the December 16, 2011, United States Department of Health and Human Services bulletin, the United States Department of Health and Human Services requires that states choose in the third quarter of 2012 one (1) of the following benchmark health insurance plans to serve as a reference for providing EHB in nongrandfathered health plans:

4. (i) The largest plan by enrollment in any of the three (3) largest small group insurance products in the state’s small group market;

   1. (ii) Any of the largest three (3) state employee health benefit plans by enrollment;

      1. (iii) Any of the largest three (3) national FEHBP plan options by enrollment; or

         1. (iv) The largest insured commercial non-Medicaid health maintenance organization operating in the state.

      2. (B) The United States Department of Health and Human Services further provides that if a state does not exercise its option to select a benchmark health plan, the default benchmark health plan for that state is the largest plan by enrollment in the largest product in the state's small group market.

         1. (d)
   2. (1) The purpose of this part is to provide guidance for selecting the benchmark plan for establishing EHB for nongrandfathered health plans offered through the exchange operating in the state as well as for nongrandfathered plans offered in the individual and small group markets outside the exchange in the state.
   3. (2) In addition, this part shall define the criteria or standards that are the basis for the selection of the benchmark health plan.

Codification Notes: Section 1302(b) of the Affordable Care Act is codified at 42 U.S.C. § 18022(b).