Section 2001.11  Essential Health Benefits

a)         Coverage for Essential Health Benefits Package

1)         A health insurance issuer that offers health insurance coverage in the individual or small group market shall ensure that the coverage includes an essential health benefits (EHB) package in accordance with the requirements in subsections (b) and (c). (See 42 USC 300gg-6(a).)

2)         The provisions of this Section regarding the inclusion of essential pediatric oral care benefits shall be deemed to be satisfied for qualified health plans made available in the small group market or individual market in Illinois outside the Health Benefits Exchange, issued for policy or plan years beginning on or after January 1, 2015, that do not include the essential pediatric oral care benefits if the health insurance issuer has obtained reasonable assurance that the pediatric oral care benefits are provided to the purchaser or enrollee of the qualified health plan. The health insurance issuer shall be deemed to have obtained reasonable assurance that the pediatric oral care benefits are provided to the purchaser of the qualified health plan if:

A)        At least one Exchange certified stand-alone dental plan that offers the minimum essential pediatric oral care benefits that are required under subsection (c)(1)(J) and it is available for purchase by the small group or individual purchaser;

B)        The health insurance issuer prominently discloses to the purchaser, or enrollee in the case of a group plan, in a form approved by the Director, at the time that it offers the qualified health plan, that the plan does not provide the essential pediatric oral care benefits; and

C)        The health insurance issuer has received and kept records of written, verbal or electronic confirmation from the purchaser, or enrollee in the case of a group plan, that he or she has obtained, or is obtaining, other coverage that includes essential pediatric oral care benefits.

b)         Essential Health Benefits Package

In this Section, the term "essential health benefits package" means, with respect to any health plan, coverage that:

1)         provides for the essential health benefits defined under subsection (c);

2)         limits cost-sharing for such coverage in accordance with Section 2001.12(a); and

3)         subject to Section 2001.12(i), provides either the bronze, silver, gold or platinum level of coverage described in Section 2001.12(b). (See 42 USC 18022(a) and (b).)

c)         Essential Health Benefits

1)         In General

Subject to subsection (c)(2), essential health benefits shall include at least the following general categories and the items and services covered within the categories:

A)        Ambulatory patient services;

B)        Emergency services;

C)        Hospitalization;

D)        Maternity and newborn care;

E)        Mental health and substance use disorder services, including behavioral health treatment;

F)         Prescription drugs;

G)        Rehabilitative and habilitative services and devices;

H)        Laboratory services;

I)         Preventive and wellness services and chronic disease management; and

J)         Pediatric services, including oral and vision care. (See 42 USC 18022(a) and (b).)

2)         Specific Requirements

Essential health benefits shall include:

A)        For plan years 2017-2019, those specific benefits and limits described in the Illinois EHB Benchmark Plan selected from the Blue Cross Blue Shield of Illinois plan in the Small Group Market designated "Blue PPO Gold 011", published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (http://www.cms.gov/CCIIO/

Resources/Data-Resources/Downloads/IL-BMP.zip). 

B)        For plan years 2020 onward, those specific benefits and limits described in the Illinois EHB Benchmark Plan designated "The Access to Care and Treatment Plan", published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244  (http://www.cms.gov/CCIIO/

Resources/Data-Resources/Downloads/2020-BPM-IL.zip).

This subsection (c)(2) does not include any later amendments or editions, if any, to the Illinois EHB Benchmark Plans.

(Source:  Amended at 43 Ill. Reg. 9378, effective August 26, 2019)