HHS Asks Public What Counts as Essential Health Benefits
Published Date: 6/15/2026
Proposed Rule
Summary
CMS wants your thoughts on the Essential Health Benefits (EHB) rules that decide what health care must be covered by insurance plans. This review affects people buying health insurance and employers offering plans, aiming to make sure benefits match typical employer plans and keep costs fair. Comments are open until July 15, 2026, and could lead to changes that impact what’s covered and how much you pay.
Analyzed Economic Effects
6 provisions identified: 2 benefits, 0 costs, 4 mixed.
Who Must Cover Essential Health Benefits
If you have a non-grandfathered individual or small-group health plan, your plan must cover the Essential Health Benefits (EHB) package as required by the Affordable Care Act; Section 2707 extends this requirement to such plans whether or not they are offered through an Exchange. This requirement applies to plans subject to EHB rules regardless of where you buy the plan.
Comprehensive Review Could Change Coverage and Costs
CMS is conducting a comprehensive review of the Essential Health Benefits (EHB) framework and the typical employer plan standard and is seeking public comment through July 15, 2026. The information CMS gathers could lead to future regulatory changes that affect what is covered as EHB and how much consumers and employers pay.
The Ten Essential Health Benefit Categories
Essential Health Benefits (EHB) must include at least these ten 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. These categories define the minimum areas that applicable plans must cover.
Pause on State EHB Application Reviews
CMS has paused review of State applications to modify their EHB-benchmark plans pursuant to 45 CFR 156.111 for plan years beginning on or after January 1, 2027. This pause means State-requested benchmark updates for PYs starting January 1, 2027 are not being processed while CMS conducts its comprehensive review.
2025 Rule Changed State Update Options Starting PY2026
The 2025 Notice of Benefit and Payment Parameters revised 45 CFR 156.111 so that, beginning in plan year 2026, States can no longer adopt another State's EHB-benchmark plan in whole or replace individual EHB categories as the first two specific options for updating benchmarks. The typicality standard was also amended and the generosity standard was removed.
State Variation Persists; 12 States Updated Benchmarks
Since the 2019 Payment Notice established an application process, 12 States have updated their EHB-benchmark plans while the remaining States generally continue to use the EHB benchmarks that became applicable in plan year 2017. This means coverage scope and premiums can vary by State based on each State's benchmark.
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