Proposed Rule2026-11994
Request for Information; Comprehensive Review of the Essential Health Benefits Framework and Typical Employer Plan Standard
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Published
June 15, 2026
Issuing agencies
Health and Human Services Department
Abstract
This request for information (RFI) seeks public input to support CMS' comprehensive review of the Essential Health Benefits (EHB) framework and the requirement under the Patient Protection and Affordable Care Act (Affordable Care Act) that the scope of EHB be equal to the scope of benefits provided under a typical employer plan. CMS seeks comment on current interpretations of EHB, State approaches to selecting and updating EHB-benchmark plans, and methodologies used to determine the scope of benefits included as EHB, as well as how these approaches relate to access and market stability under the Affordable Care Act. CMS also seeks comment on variation across States in the scope of benefits included as EHB, cost pressures affecting EHB, processes for updating State EHB-benchmark plans, limitations in available data used to evaluate EHB, and potential impacts of possible future policy changes. The information gathered will inform CMS' evaluation of whether revisions or additions to the current EHB regulations through future notice and comment rulemaking may be appropriate.
Full Text
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<title>Federal Register, Volume 91 Issue 114 (Monday, June 15, 2026)</title>
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[Federal Register Volume 91, Number 114 (Monday, June 15, 2026)]
[Proposed Rules]
[Pages 35938-35944]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2026-11994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
45 CFR Part 156
[CMS-9874-NC]
RIN 0938-AW02
Request for Information; Comprehensive Review of the Essential
Health Benefits Framework and Typical Employer Plan Standard
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health and Human Services (HHS).
ACTION: Request for information.
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SUMMARY: This request for information (RFI) seeks public input to
support CMS' comprehensive review of the Essential Health Benefits
(EHB) framework and the requirement under the Patient Protection and
Affordable Care Act (Affordable Care Act) that the scope of EHB be
equal to the scope of benefits provided under a typical employer plan.
CMS seeks comment on current interpretations of EHB, State approaches
to selecting and updating EHB-benchmark plans, and methodologies used
to determine the scope of benefits included as EHB, as well as how
these approaches relate to access and market stability under the
Affordable Care Act. CMS also seeks comment on variation across States
in the scope of benefits included as EHB, cost pressures affecting EHB,
processes for updating State EHB-benchmark plans, limitations in
available data used to evaluate EHB, and potential impacts of possible
future policy changes. The information gathered will inform CMS'
evaluation of whether revisions or additions to the current EHB
regulations through future notice and comment rulemaking may be
appropriate.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, by July 15, 2026.
ADDRESSES: In commenting, refer to file code CMS-9874-NC.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to <a href="https://www.regulations.gov/docket/CMS-2026-2081">https://www.regulations.gov/docket/CMS-2026-2081</a>. Follow
the ``Submit a comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention:
[[Page 35939]]
CMS-9874-NC, P.O. Box 8016, Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-9874-NC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: LeAnn Brodhead, (667) 290-8805.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received at <a href="https://www.regulations.gov">https://www.regulations.gov</a>. Follow the search instructions on that website to
view public comments. CMS will not post on <a href="http://Regulations.gov">Regulations.gov</a> public
comments that make threats to individuals or institutions or suggest
that the commenter will take actions to harm an individual. CMS
continues to encourage individuals not to submit duplicative comments.
We will post acceptable comments from multiple unique commenters even
if the content is identical or nearly identical to other comments.
I. Background
Section 1301(a)(1)(B) of the Affordable Care Act \1\ requires
qualified health plans (QHPs) to cover the Essential Health Benefits
(EHB) package described in section 1302(a) of the Affordable Care Act,
which includes coverage of the services described in section 1302(b) of
the Affordable Care Act. Section 2707(a) of the Public Health Service
Act extends this requirement to non-grandfathered individual and small
group health insurance coverage (hereinafter referred to as plans
subject to EHB requirements) irrespective of whether such coverage is
offered through an Exchange.
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\1\ The Patient Protection and Affordable Care Act (Pub. L. 111-
148) was enacted on March 23, 2010. The Healthcare and Education
Reconciliation Act of 2010 (Pub. L. 111-152), which amended and
revised several provisions of the Patient Protection and Affordable
Care Act, was enacted on March 30, 2010. In this RFI, the two
statutes are referred to collectively as the ``Patient Protection
and Affordable Care Act,'' or ``Affordable Care Act''.
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Section 1302(a) of the Affordable Care Act provides for the
establishment of this EHB package to include coverage of the EHB (as
defined by the Secretary of HHS (Secretary)), cost-sharing limits, and
actuarial value (AV) requirements. Section 1302(b) of the Affordable
Care Act directs the Secretary, in defining the EHB, to ensure that
they are equal in scope to the benefits provided under a typical
employer plan and that they include at least the following ten
statutory benefit categories and the items and services covered within
the categories: ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and
substance use disorder services, including behavioral health treatment;
prescription drugs; rehabilitative and habilitative services and
devices; laboratory services; preventive and wellness services and
chronic disease management; and pediatric services, including oral and
vision care. In addition, section 1302(d) of the Affordable Care Act
establishes AV standards for plan coverage. Section 1302(b)(4)(A) and
section 1302(b)(4)(G)(i) of the Affordable Care Act further direct the
Secretary to ensure that such EHB reflect an appropriate balance among
the benefit categories so that benefits are not unduly weighted toward
any category when defining EHB and to assess whether enrollees are
facing any difficulty accessing needed services for reasons of coverage
or cost when reviewing EHB, respectively. Sections 1302(b)(4)(G)(ii)
and (iv) of the Affordable Care Act direct the Secretary to
periodically review EHB to assess whether the EHB needs to be modified
or updated to account for any changes in medical evidence or scientific
advancement, and how benefit changes affect costs.
HHS initially outlined its intended regulatory approach to defining
EHB, including a State benchmark-based approach, in a 2011 bulletin.\2\
We subsequently finalized implementing regulations related to EHB in
the Standards Related to Essential Health Benefits, Actuarial Value,
and Accreditation final rule, which appeared in the February 25, 2013
Federal Register (78 FR 12834) (EHB Rule). As set forth in the EHB
Rule, for a non-grandfathered individual or small group market health
plan to provide the required EHB package, the health plan must, among
other things, provide the benefits in accordance with the State's EHB-
benchmark plan, as described at 45 CFR 156.115. A State's EHB-benchmark
plan serves as a reference plan for the benefits considered as EHB in
the State. This State benchmark-based framework gives States
flexibility in defining EHB in their respective States.
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\2\ The HHS EHB bulletin is available on the CMS website at
<a href="https://www.cms.gov/CCIIO/Resources/Files/Downloads/essential_health_benefits_bulletin.pdf">https://www.cms.gov/CCIIO/Resources/Files/Downloads/essential_health_benefits_bulletin.pdf</a>.
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For plan years (PYs) 2014 through 2016, States were required to
select--or default to--one of ten ``typical'' employer plans identified
at Sec. 156.100, all of which were based on 2012 plan designs, with
any missing benefit categories supplemented as specified under Sec.
156.110.\3\ States were required to select base-benchmark plans (that
is, the reference plan used to determine the specific items and
services included as EHB in a State) from among the following four
types of health plans: (1) the largest plan by enrollment in any of the
three largest small group insurance products in the State's small group
market as defined in Sec. 155.20; (2) any of the largest three State
employee health benefit plans by enrollment; (3) any of the largest
three national Federal Employees Health Benefits Program (FEHBP) plan
options by enrollment that are open to Federal employees under 5 U.S.C.
8903; or (4) the largest insured commercial non-Medicaid HMO operating
in the State.
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\3\ As specified by Sec. 156.100(c), for PYs beginning prior to
January 1, 2020, if a State did not make an EHB-benchmark selection
using the process described in the section, the State's EHB-
benchmark defaulted to the largest plan by enrollment in the largest
product by enrollment in the State's small group market.
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For PYs 2017, 2018, and 2019, States retained these same base-
benchmark plan options; however, the underlying reference plans were
updated from 2012 plans to 2014 plan designs pursuant to revisions to
the EHB regulations finalized in the HHS Notice of Benefit and Payment
Parameters for 2017 final rule, which appeared in the March 8, 2016
Federal Register (81 FR 12204) (2017 Payment Notice). In most States,
the EHB-benchmark plans from this period remain in effect today.
The HHS Notice of Benefit and Payment Parameters for 2019 final
rule, which appeared in the April 17, 2018 Federal Register (83 FR
16930) (2019 Payment Notice), added Sec. 156.111 to provide States
with additional options from which to select an EHB-benchmark plan for
PYs 2020 and beyond. In that final rule, we stated that we believe
States should have additional choices with respect to benefits and
affordable coverage, and we added Sec. 156.111 to provide additional
flexibility for States
[[Page 35940]]
to select new EHB-benchmark plans starting with the 2020 PY.
Specifically, we expanded State flexibility by allowing States to
update their EHB-benchmark plans using one of three approaches: (1)
selecting the EHB-benchmark plan that another State used for the 2017
PY; (2) replacing one or more EHB categories of benefits in its EHB-
benchmark plan used for the 2017 PY with the same category or
categories of benefits from another State's EHB-benchmark plan used for
the 2017 PY; or (3) otherwise selecting a set of benefits that would
become the State's EHB-benchmark plan.\4\ We also established
typicality and generosity standards requiring States to demonstrate
that the total AV of their EHB is no more or less generous than the
total AV in the State's most and least generous typical employer plans,
reducing outliers while providing a consistent ceiling on the EHB that
is specific and relative to each State. Typicality required that
benefits be equal in scope to those of a typical employer plan, defined
as one of the original ten base-benchmark plan options or the largest
plan by enrollment among one of the five largest group products in the
State, given other regulatory conditions were met, effectively giving
States fifteen potential comparison plans.\5\ The generosity standard
required that updated benefits not be more generous than a comparison
plan, defined as the benchmark plan used for PY 2017 or any of the
base-benchmark options available for that PY.
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\4\ Section 156.111(a).
\5\ The ``typicality'' standard for EHB is codified in 45 CFR
156.111(b)(2). Under this provision, a State's EHB-benchmark plan
must provide a scope of benefits equal to the scope of benefits
provided under a typical employer plan; for PYs 2020 through 2025,
this was defined either as one of the State's 10 base-benchmark plan
options from Sec. 156.100 or the largest large-group health plan by
enrollment in the State. <a href="https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-156/subpart-B/section-156.111">https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-156/subpart-B/section-156.111</a>.
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In the HHS Notice of Benefit and Payment Parameters for 2025 final
rule, which appeared in the April 15, 2024 Federal Register (89 FR
26218) (2025 Payment Notice), we finalized revisions to Sec. 156.111
that eliminated the first two options for States to update their EHB-
benchmark plans--adopting another State's EHB-benchmark plan in whole
or replacing individual EHB categories--beginning in PY 2026 on the
basis that they were subsets of the broader option to create a new EHB-
benchmark plan. We also amended the typicality standard so that in
demonstrating that a State's new EHB-benchmark plan provides a scope of
benefits that is equal to the scope of benefits of a typical employer
plan in the State, the scope of benefits of a typical employer plan in
the State is defined as any scope of benefits that is as or more
generous than the scope of benefits in the State's least generous
typical employer plan, and as or less generous than the scope of
benefits in the State's most generous typical employer plan, from a
defined set of plans identified as typical employer plans. In addition,
we removed the generosity standard.
Since establishing a process by which States can apply to update
their EHB-benchmark plans in the 2019 Payment Notice, 12 States have
updated their EHB-benchmark plans, while the remaining States have
continued to use the EHB-benchmark plans that became applicable in PY
2017.
II. Solicitation of Public Comments
In the HHS Notice of Benefit and Payment Parameters for 2027 final
rule, which appeared in the May 20, 2026 Federal Register (91 FR 29526)
(2027 Payment Notice), we noted that we paused review of State
applications to modify their EHB-benchmark plans pursuant to 45 CFR
156.111 for PYs beginning on or after January 1, 2027. We also noted
that we are conducting a comprehensive review of section 1302 of the
Affordable Care Act and the Secretary's statutory responsibilities
under that provision.
We are engaging in a renewed examination of the EHB framework in
light of significant changes in the health insurance and health care
landscape, including changes in employer-sponsored insurance coverage,
advances in health care innovations and delivery, shifts in the
utilization of services, and rising health care costs. These changes
necessitate examination of whether existing approaches to defining EHB,
methodologies used to determine whether benefits are ``typical'' of
employer coverage, and scope of benefits included as EHB continue to
reflect current market conditions and support the statutory goals of
affordability and access to care under the Affordable Care Act. For
purposes of this RFI, the term ``benefits'' refers to items and
services, including medical services, treatments, procedures, and
covered goods and is intended to encompass the full scope of covered
health care services and products unless otherwise specified.
We request comments from all interested parties on several topics
related to EHB, including the general EHB framework and the typicality
standard. Collectively, these comments will assist CMS in identifying
areas where further analysis or potential future rulemaking may be
appropriate.
Commenters are encouraged to identify the specific section and
question number(s) (for example, Topic 2, Question 2.1; Topic 4,
Question 4.3) addressed in each portion of their submission and to
organize comments consistent with the structure of this RFI. Where
applicable, commenters are encouraged to provide supporting data,
citations to relevant statutory or regulatory provisions, and
quantitative analyses to substantiate their views.
Topic 1: Typical Employer Plans and Typicality
The following questions relate to the statutory requirement at
section 1302(b)(2)(A) of the Affordable Care Act that the Secretary
ensure the scope of EHB is equal to the scope of benefits provided
under a typical employer plan, as determined by the Secretary. CMS
recognizes that changes to the interpretation of ``typical employer
plan'' and ``equal in scope'' could affect affordability, market
stability, State flexibility, and access to services by influencing
which benefits are required to be covered as EHB and the degree of
variation permitted across State EHB-benchmark plans.
Question 1.1 (Typical Employer Plan)
The current regulatory framework for identifying a ``typical
employer plan'' as reflected in the EHB-benchmark plan selection
framework established under Sec. Sec. 156.100 and 156.111(b)(2),
includes the following plan types:
<bullet> Government employee plans (Federal and State);
<bullet> Small group plans;
<bullet> Large group plans; and
<bullet> Self-funded plans.
However, the statute does not specifically require CMS to use a
reference plan approach when defining the EHB or ensuring typicality
and there are many ways that typicality could be assessed. What
considerations, including data availability, representativeness of
typical employer plan coverage, and administrative feasibility, should
CMS consider when evaluating whether it is appropriate to propose
policy changes related to typicality and whether changes to the current
framework of a ``typical employer plan'' are warranted? Are certain
types of plans more representative of a typical employer plan than
others? Are there other ways that CMS could define and/or assess
typicality that are not based on a reference plan approach, such as
through a survey of commonly covered benefits within the 10 categories
of EHB
[[Page 35941]]
or a review of existing data sets (for example, commercial claims data
or employer-sponsored coverage surveys)? When considering typicality,
should CMS consider employer size? When selecting or designing an EHB-
benchmark plan, States have overwhelmingly relied on small group plans
as a reference. Is there something inherently more ``typical'' about
these plans such that they are more readily selected, or is this due to
factors such as data availability? Are self-funded plans, which cover
more than half of people with employer-sponsored coverage,
insufficiently represented, and if not, how could CMS use data related
to self-funded plans to improve how typicality is defined?
Question 1.2 (Defining Scope of Plan Benefits)
Under current EHB policy, the scope of benefits of a typical
employer plan is based on comparison to specific reference plans within
the EHB-benchmark framework, rather than a standardized actuarial
value-based definition. What advantages or drawbacks should CMS
consider when considering whether to define the scope of benefits of a
typical employer plan based on AV, as opposed to a definition based on
a specific set of benefits or another alternative methodology? We seek
comment on considerations such as transparency, data limitations,
comparability across plans, and administrative feasibility.
Question 1.3 (Typical Employer Plan Selection Approach)
Under current EHB policy, States must select from specified subsets
of typical employer plans when selecting or updating the State's EHB-
benchmark plan. As discussed previously, some of these typical employer
plan options are limited to plans that were available in the 2017 PY,
while others are available in any PY after 2017. We seek comment on
whether and how this approach, including the defined set of plan
options and associated constraints, could be refined, as appropriate,
to continue to reflect the statutory requirement that EHB be equal in
scope to benefits provided under a typical employer plan. What
additional or alternative limits, if any, would be reasonable to apply
to the use of historical plans (for example, limiting selection to
plans that were in effect more than a specified number of years prior;
tied to the EHB-benchmark plan selection year, etc.)? Are there
modifications to the types of plans included in the current set of
options, or to how CMS selects the plan options available to States,
that could further support representation of a typical employer plan?
Are there alternative ways CMS could structure or refine the current
approach, including the use of plan options or the current requirement
that EHB-benchmark plans fall within the range of the least and most
generous typical employer plans, to maintain consistency with the
statutory standard? In responding, we request that commenters address
considerations related to market evolution, medical or scientific
advancements, data reliability, and consistency across States.
Topic 2: State Selection of EHB-Benchmark Plans--National Standards and
Variation Across States
The current EHB framework allows States to select EHB-benchmark
plans that reflect their health insurance markets and population needs.
This State-based approach has resulted in variation in the scope of
benefits included as EHB across the 51 current EHB-benchmark plans. For
example, premium rates and coverage of different benefits vary from
State to State. We seek to better understand how this State variation
affects consumers, issuers, and State regulators.
Question 2.1 (Overall Impacts Associated with Variation Across States)
To what extent does variation in the scope of benefits included as
EHB across States affect consumers, issuers, and State regulators?
Please describe specific impacts on:
<bullet> Plan availability;
<bullet> Consumer education;
<bullet> Issuer operations;
<bullet> State regulation and enforcement; and
<bullet> Market competition.
Question 2.2 (Benefits Associated With Variation Across States)
What are the advantages of State flexibility in defining the scope
of EHB? How does State flexibility facilitate:
<bullet> Responsiveness to State-specific population needs;
<bullet> Innovation in benefit design and coverage approaches; and
<bullet> Alignment with State regulations and market conditions?
Question 2.3 (Challenges Associated With Variation Across States)
What challenges result from variation across States in the scope of
benefits included as EHB? For example, consider:
<bullet> Administrative or compliance burden on issuers; and
<bullet> Potential differences in access to EHB based on State of
residence, and potential variation in specific benefit categories (for
example, maternity and newborn care, rehabilitative and habilitative
services and devices, etc.).
Question 2.4 (Evaluation of the Scope of Benefits Included as EHB
Across States)
What methodologies, data sources, or metrics should CMS use to
evaluate and compare the scope of benefits included as EHB across
States and in relation to typical employer plans? In responding,
commenters are encouraged to address claims-based measures, including
how differences in prices, service use, and population health may
affect comparisons of the scope of benefits included as EHB across
States.
Question 2.5 (Variation Across Markets and Populations)
How should CMS interpret differences in health care costs and
utilization when comparing the scope of benefits included as EHB across
States or plan markets, given that claims data may reflect other
factors such as differences in prices, cost of living, or population
health?
Topic 3: Affordability and Cost
Since the implementation of EHB requirements under section 1302 of
the Affordable Care Act and implementing regulations beginning in 2014,
health care delivery models, utilization patterns, and clinical
practices have evolved, and overall health care spending has
increased.<SUP>8 9</SUP> We seek comment on how the scope of benefits
included as EHB affects premiums, consumer affordability, and long-term
market stability. Additionally, we seek input on whether and how
affordability considerations should inform assessments of whether the
scope of EHB is equal in scope to benefits provided under a typical
employer plan, consistent with section 1302(b)(2)(A) of the Affordable
Care Act.
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\8\ Centers for Medicare & Medicaid Services, Office of the
Actuary, National Health Expenditure Data; Agency for Healthcare
Research and Quality, National Healthcare Quality and Disparities
Report, available at <a href="https://www.ahrq.gov/research/findings/nhqrdr/index.html">https://www.ahrq.gov/research/findings/nhqrdr/index.html</a>.
\9\ Centers for Disease Control and Prevention, Health, United
States, available at <a href="https://www.cdc.gov/nchs/hus/index.htm">https://www.cdc.gov/nchs/hus/index.htm</a>.
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Question 3.1 (EHB-Related Premium Drivers)
What specific aspects of EHB most significantly influence premium
levels in the individual and small group markets? In responding,
commenters are encouraged to identify specific EHB categories,
services, or coverage features that contribute to cost growth, such as
high-cost therapies, utilization-intensive
[[Page 35942]]
services, or coverage parameters (for example, limits on services or
duration of treatment). To what extent does the scope or breadth of
coverage within specific EHB categories contribute to premium
increases? Are there specific EHB categories, services, or coverage
features that do not contribute to cost growth? Have employer plans,
especially self-funded plans, implemented changes to plan design
features to mitigate cost growth that would lower premiums for plans
subject to EHB requirements?
Question 3.2 (Issuer Cost Management Strategies)
How do issuers, employers, and other interested parties manage
costs associated with benefits included as EHB, including through
benefit design, utilization management techniques, network design, or
payment approaches? To what extent do current EHB requirements
influence or constrain these cost-management strategies, including how
such tools affect affordability and enrollee access to medically
necessary care?
Question 3.3 (Coverage and Affordability Tradeoffs)
What factors should CMS consider when evaluating potential
tradeoffs between the scope of benefits included as EHB and
affordability for consumers, issuers, and Federal taxpayers? In
responding, commenters are encouraged to address:
<bullet> How State regulators currently evaluate such tradeoffs
when designing or regulating EHB coverage;
<bullet> How mismatches between EHB and benefits covered by a
typical employer plan might introduce adverse selection risks between
individual and group plans;
<bullet> To what extent CMS should consider that the generosity of
EHB affects Federal expenditures through premium tax credits and cost-
sharing reductions, in evaluating the appropriate scope of benefits
included as EHB; and
<bullet> What data or empirical evidence should inform assessments
of tradeoffs between an expanded scope of benefits and potential
offsets elsewhere in plan design (for example, changes in cost-sharing
or coverage limitations) relative to a typical employer plan.
Question 3.4 (Measurement of Affordability and Cost)
What data sources, analytic methods, or research approaches should
CMS rely on to evaluate the relationship between the scope of benefits
included as EHB, premiums, consumer affordability, and long-term
stability of the individual and small group markets?
Question 3.5 (Emerging Costs and Future Trends)
Are there emerging trends in health care delivery, utilization, or
technology that interested parties believe may influence the
affordability of benefits included as EHB in future PYs? If so, how
should CMS consider these trends when periodically reviewing EHB as
required by section 1302(b)(4)(G) of the Affordable Care Act?
Topic 4. Scope of Benefits Included as EHB
We seek comment on how CMS should define and evaluate the scope of
EHB, including methodological approaches, employer-sponsored coverage
patterns, and how considerations such as clinical effectiveness,
preventive services, and population health outcomes may inform which
services are reflected in the scope of benefits included as EHB. For
purposes of this section, the scope of benefits may include covered
services, treatment approaches, coverage limitations, medical
management, and other benefit design features that affect access to
care and health outcomes.
Question 4.1 (Employer-Sponsored Plan Coverage Outside EHB)
Do employer-sponsored plans routinely cover benefits that are not
EHB? What are the most commonly covered benefits by employer-sponsored
plans that are not EHB?
Question 4.2 (Factors Informing Scope of Benefits Included as EHB)
What factors should CMS consider when evaluating benefits included
as EHB considering the evolution of health care delivery, clinical
standards of care, and statutory requirements related to a typical
employer plan? For example, should CMS consider:
<bullet> AV and cost-sharing levels (for example, whether the scope
of benefits allows plans to meet AV requirements and how the scope of
benefits affects consumer out-of-pocket costs);
<bullet> Breadth of covered services within each EHB category;
<bullet> Alignment with clinical guidelines and evidence-based
practices;
<bullet> Consistency with employer-sponsored coverage; and
<bullet> Impact on premium affordability?
Question 4.3 (Defining Scope Within Select EHB Categories)
How should CMS evaluate the appropriate scope of benefits within
the 10 EHB categories, specifically with regard to behavioral health,
preventive care, and chronic disease management, to ensure coverage
remains clinically appropriate and consistent with statutory
requirements?
Question 4.4 (Level of Detail for Defining and Analyzing EHB)
Section 1302(b)(1) of the Affordable Care Act provides that EHB
must include ``at least the following general categories and the items
and services covered within the categories,'' as further described in
the statute. At what level of detail and using what analytical methods
should EHB coverage be defined in EHB-benchmark plans? For example,
coverage for ``inpatient hospital services'' may include many more
specific ``sub-benefits'' and without additional detail, there can be
ambiguity in which of the specific ``sub-benefits'' should be
considered covered within ``inpatient hospital services.'' How should
CMS or States ensure that the items and services within each EHB
category are appropriately reflected in EHB-benchmark plans?
Question 4.5 (Preventive and Wellness Services, Behavioral Health
Services, Chronic Disease Management, and Health Outcomes)
How do current EHB policies support coverage of preventive and
wellness services, behavioral health services, and chronic disease
management and how should CMS or States evaluate the role of such
services in improving health outcomes and influencing long-term
affordability when determining the scope of benefits included as EHB?
Topic 5. Updating EHB
Section 1302(b)(4)(G)(i), (ii), and (iv) of the Affordable Care Act
direct the Secretary to periodically review EHB to assess whether
enrollees are facing any difficulty accessing needed services for
reasons of coverage or cost, whether the EHB needs to be modified or
updated to account for any changes in medical evidence or scientific
advancement, and the potential of additional or expanded benefits to
increase costs, respectively. The following questions address the
frequency and criteria for EHB reviews, safeguards to ensure
consistency with typical employer plan coverage, and how the EHB
framework can accommodate changes over time.
Question 5.1 (Frequency of EHB Coverage Review)
How frequently should CMS review EHB coverage, consistent with
section 1302(b)(4)(G) of the Affordable Care Act, and consider whether
updates to
[[Page 35943]]
regulations implementing EHB may be appropriate?
<bullet> Should there be a regular review cycle (for example, every
3-5 years)?
<bullet> Should EHB reviews be event-driven based on specific
triggers or indicators? If event-driven, what factors should prompt CMS
to initiate a review (for example, significant changes in medical
practices and clinical guidelines, new technological innovations,
shifts in employer coverage patterns, identified gaps in consumer
coverage, public health emergencies, etc.), and what data source(s)
(such as for covered employer benefits) would be relevant to determine
when the threshold has been met to prompt such review?
<bullet> What are the advantages and disadvantages of implementing
a formal review schedule versus maintaining flexibility to conduct
reviews of EHB coverage as needed? Do States have the resources to
support such reviews?
Question 5.2 (EHB Safeguards)
What, if any, mechanisms or safeguards should be in place to ensure
that EHB updates maintain consistency with the statutory requirement
that the scope of EHB be equal to the scope of benefits provided under
a typical employer plan pursuant to section 1302(b)(2)(A) of the
Affordable Care Act?
Question 5.3 (EHB Framework Adaptability)
How could the EHB framework more effectively support innovation and
adapt to:
<bullet> Changes in medical advancements or clinical guidelines;
<bullet> Emerging health care delivery models (for example,
telehealth, value-based care);
<bullet> Regional variations in health care needs and priorities;
and
<bullet> Promotion of both stability and flexibility in benefit
design?
Topic 6. State Processes for Updating EHB-Benchmark Plans
Since establishing an application process for States to update
their EHB-benchmark plans in the 2019 Payment Notice, 12 States have
updated their EHB-benchmark plans.\10\ As part of this process, States
submit proposed updates for review, consistent with applicable
statutory and regulatory standards, including the requirement that the
scope of benefits be equal to the scope of benefits provided under a
typical employer plan as required by section 1302(b)(2)(A) of the
Affordable Care Act. We seek comment on considerations related to the
structure and operation of the EHB-benchmark plan update process,
including the respective roles of CMS and States, and how this process
functions in practice while preserving State flexibility.
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\10\ Centers for Medicare & Medicaid Services (CMS), Information
on Essential Health Benefits (EHB) Benchmark Plans, available at
<a href="https://www.cms.gov/marketplace/resources/data/essential-health-benefits">https://www.cms.gov/marketplace/resources/data/essential-health-benefits</a>.
---------------------------------------------------------------------------
Question 6.1 (Experience With the EHB-Benchmark Plan Application
Process)
Based on your experience with the current EHB-benchmark plan
application process, please describe:
<bullet> Aspects of the process that work well and should be
maintained; and
<bullet> Challenges or limitations encountered during the
application process.
Question 6.2 (EHB-Benchmark Plan Application Process Improvements)
What improvements to the EHB-benchmark plan application process
would you recommend? Please provide specific suggestions regarding:
<bullet> Application requirements, documentation, or submission
process that could be clarified, simplified, or streamlined;
<bullet> Technical assistance from CMS during the EHB-benchmark
plan application process, and what resources or support would be most
helpful to States and other interested parties;
<bullet> The timing of State applications for EHB-benchmark plan
updates (for example, the time required for States to research and
submit applications and for CMS to review applications, particularly in
relation to when the new EHB-benchmark plan would be effective); and
<bullet> Any other aspects of the application process that could be
improved to address current challenges or limitations encountered
during the process.
Question 6.3 (Impacts of Changes to EHB-Benchmark Plan Application
Requirements and Review Process)
How might changes to EHB-benchmark plan application requirements or
CMS review processes impact:
<bullet> Application preparation and documentation requirements;
<bullet> Timeline for CMS review of EHB-benchmark plan
applications; and
<bullet> Interested parties' engagement?
Question 6.4 (Balancing Federal Oversight and State Flexibility)
How could CMS balance Federal oversight with State flexibility in
the EHB-benchmark plan selection process? What level of CMS involvement
in benefit-by-benefit analysis would be appropriate?
For example:
<bullet> Should CMS review be limited to ensuring overall
compliance with statutory and regulatory requirements?
Topic 7. Market Stability and Considerations Related to Implementation
of Potential Refinements to the EHB Framework
We recognize that potential changes to how EHB are defined,
interpreted, or updated may create short-term transition and
operational challenges. While other sections of this RFI address
affordability, State variation, typicality, and the scope of benefits
included as EHB, this section focuses specifically on implementation of
any future proposed changes, including timing, transition safeguards,
and minimizing unintended market and coverage disruptions. We seek
public comments on the following questions:
Question 7.1 (Market Stability Impacts)
If CMS were to refine how EHB are defined, interpreted, or updated,
what short-term market disruption risks should CMS consider?
<bullet> What indicators (for example, enrollment volatility,
premium fluctuations, plan withdrawals) would signal market disruption?
<bullet> How should CMS distinguish between temporary transition
effects and longer-term structural market instability?
Question 7.2 (Implementation and Operational Considerations)
What implementation sequencing and operational readiness
considerations should CMS evaluate when considering refining EHB
policy?
<bullet> What lead time would States and issuers require to
operationalize changes and how might that timing vary depending on the
type, scope, or complexity of such changes?
<bullet> How should CMS account for rate filing timelines, plan
certification cycles, and product development processes?
<bullet> Are phased or staggered implementation approaches
preferred? If so, how do the potential advantages of these approaches
outweigh the potential disadvantages?
Question 7.3 (Consumer Access and Coverage Stability)
How might potential refinements to the EHB framework affect
consumer continuity of coverage during transition periods?
<bullet> What safeguards could minimize consumer confusion or
unintended loss
[[Page 35944]]
of coverage for medically necessary items and services?
<bullet> What communication or transition protections should CMS
consider?
Question 7.4 (Transitional Implementation Guardrails)
<bullet> What temporary guardrails or monitoring thresholds should
CMS consider during initial implementation of potential future EHB
refinements to mitigate unintended consequences?
<bullet> What corrective tools should be available if unintended
operational or market effects emerge?
Question 7.5 (Monitoring and Evaluation Metrics)
<bullet> Following implementation of any future EHB refinements,
what targeted monitoring framework should CMS use to assess market
impacts over time without duplicating broader affordability and data
analyses addressed elsewhere in this RFI?
III. Collection of Information Requirements
This is a request for information (RFI) only. In accordance with
the implementing regulations of the Paperwork Reduction Act of 1995
(PRA), specifically 5 CFR 1320.3(h)(4), this general solicitation is
exempt from the PRA. Facts or opinions submitted in response to general
solicitations of comments from the public, published in the Federal
Register or other publications, regardless of the form or format
thereof, provided that no person is required to supply specific
information pertaining to the commenter, other than that necessary for
self-identification, as a condition of the agency's full consideration,
are not generally considered information collections and therefore not
subject to the PRA.
This RFI is issued solely for information and planning purposes; it
does not constitute a Request for Proposal (RFP), applications,
proposal abstracts, or quotations. This RFI does not commit the U.S.
Government to contract for any supplies or services or make a grant
award. Further, we are not seeking proposals through this RFI and will
not accept unsolicited proposals. Responders are advised that the U.S.
Government will not pay for any information or administrative costs
incurred in response to this RFI; all costs associated with responding
to this RFI will be solely at the interested party's expense. We note
that not responding to this RFI does not preclude participation in any
future procurement, if conducted. It is the responsibility of the
potential responders to monitor this RFI announcement for additional
information pertaining to this request. In addition, we note that CMS
will not respond to questions about the policy issues raised in this
RFI.
We will actively consider all input as we develop future regulatory
proposals or future subregulatory policy guidance. We may or may not
choose to contact individual responders. Such communications would be
for the sole purpose of clarifying statements in the responders'
written responses. Contractor support personnel may be used to review
responses to this RFI. Responses to this notice are not offers and
cannot be accepted by the Government to form a binding contract or
issue a grant. Information obtained as a result of this RFI may be used
by the Government for program planning on a non-attribution basis.
Respondents should not include any information that might be considered
proprietary or confidential. This RFI should not be construed as a
commitment or authorization to incur cost for which reimbursement would
be required or sought. All submissions become U.S. Government property
and will not be returned. In addition, we may publicly post the public
comments received, or a summary of those public comments.
Mehmet Oz, Administrator of the Centers for Medicare & Medicaid
Services, approved this document on June 11, 2026.
Robert F. Kennedy, Jr.,
Secretary, Department of Health and Human Services.
[FR Doc. 2026-11994 Filed 6-12-26; 4:15 pm]
BILLING CODE 4150-28-P
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</html>Indexed from Federal Register on June 15, 2026.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.