§ 156.115 Provision of EHB. ( a ) Provision of EHB means that a health plan provides benefits that— ( 1 ) Are substantially equal to the EHB-benchmark plan including: ( i ) Covered benefits;
( ii ) Limitations on coverage including coverage of benefit amount, duration, and scope; and
( iii ) Prescription drug benefits that meet the requirements of § 156.122 of this subpart;
( 2 ) With the exception of the EHB category of coverage for pediatric services, do not exclude an enrollee from coverage in an EHB category.
( 3 ) With respect to the mental health and substance use disorder services, including behavioral health treatment services, required under § 156.110(a)(5), comply with the requirements under section 2726 of the Public Health Service Act and its implementing regulations.
( 4 ) Include preventive health services described in § 147.130 of this subchapter.
( 5 ) With respect to habilitative services and devices— ( i ) Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings;
( ii ) Do not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices; and
( iii ) For plan years beginning on or after January 1, 2017, do not impose combined limits on habilitative and rehabilitative services and devices.
( 6 ) For plan years beginning on or after January 1, 2016, for pediatric services that are required under § 156.110(a)(10), provide coverage for enrollees until at least the end of the month in which the enrollee turns 19 years of age.
( b ) An issuer of a plan offering EHB may substitute benefits for those provided in the EHB-benchmark plan under the following conditions— ( 1 ) The issuer substitutes a benefit that: ( i ) Is actuarially equivalent to the benefit that is being replaced as determined in paragraph (b)(4) of this section; and
( ii ) Is not a prescription drug benefit.
( 2 ) An issuer may substitute a benefit within the same EHB category, unless prohibited by applicable State requirements. Substitution of benefits between EHB categories is not permitted.
( 3 ) The plan that includes substituted benefits must: ( i ) Continue to comply with the requirements of paragraph (a) of this section, including by providing benefits that are substantially equal to the EHB-benchmark plan;
( ii ) Provide an appropriate balance among the EHB categories such that benefits are not unduly weighted toward any category; and
( iii ) Provide benefits for diverse segments of the population.
( 4 ) The issuer submits to the State evidence of actuarial equivalence that is: ( i ) Certified by a member of the American Academy of Actuaries;
( ii ) Based on an analysis performed in accordance with generally accepted actuarial principles and methodologies;
( iii ) Based on a standardized plan population; and
( iv ) Determined without taking cost-sharing into account.
( c ) A health plan does not fail to provide EHB solely because it does not offer the services described in § 156.280(d) of this subchapter.
( d ) For plan years beginning on or before January 1, 2026, an issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, or non-medically necessary orthodontia as EHB. For plan years beginning on or after January 1, 2027, an issuer of a plan offering EHB may not include routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, or non-medically necessary orthodontia as EHB.
[78 FR 12866, Feb. 25, 2013, as amended at 80 FR 10871, Feb. 27, 2015; 81 FR 12349, Mar. 8, 2016; 83 FR 17069, Apr. 17, 2018; 86 FR 53506, Sept. 27, 2021; 87 FR 27390, May 6, 2022; 89 FR 26425, Apr. 15, 2024]