BENCHMARK PLAN ELECTION RULES

Benchmark Plan Election Rules

Federal departments issued final rules to ensure that Essential Health Benefits (EHBs) are not subjected to annual and lifetime dollar limits, as mandated by the Affordable Care Act (ACA).

The final rules require that, for plans years beginning on or after Jan. 1, 2017, large group insurers and self-funded plans that are not required to provide EHBs* (including ERISA self-funded plans) must define the EHBs provided in their plan consistent with one of the following:

• one of the 51 EHB benchmark plans in a state or Washington, D.C., or
• one of the three Federal Employee Health Benefit Programs.

As a result of the rules, both large group insurers and self-funded plans will, in effect, be selecting a benchmark plan or federal program to support their application of any annual or lifetime dollar limits contained in their plan. The rules apply regardless of the size of the self-funded plan and regardless of grandfathered status. The federal Departments of the Treasury, Labor and Health and Human Services issued the final rules on Nov. 18, 2015.

The Centers for Medicare and Medicaid Services (CMS) has created a list of the 51 benchmark plans and identified whether each benefit contained in each plan is an EHB. To view the plans or the determination from CMS on whether each plan’s benefits are EHBs, follow this link and read “2017 EHB Benchmark Plan Information” under each state or the District of Columbia.

Please note: For groups with plans that do not include any dollar maximums to ensure compliance with the ACA mandate prohibiting annual and lifetime dollar limits, election of a benchmark plan or federal program would appear to be unnecessary.

*ERISA self-funded plans do not have to include 10 categories of benefits known as Essential Health Benefits (EHBs). However, if such self-funded plans do include EHBs, they are prohibited from imposing lifetime or annual dollar limits on these benefits. Certain non-ERISA self-funded plans may be required by applicable state laws to provide Essential Health Benefits.