The EHB benchmark plan is the state-designated reference plan that sets the minimum coverage floor for every ACA Qualified Health Plan sold in that state. A Silver plan in Illinois and a Silver plan in Texas share the same actuarial value target and the same ten EHB category headings. They do not necessarily cover the same services within those categories.
Key Takeaways
- The EHB benchmark plan is the state-designated reference plan that sets the minimum covered-services floor for every ACA QHP sold in that state.
- Illinois, Montana, Rhode Island, Connecticut, and New Jersey cover infertility treatment under their benchmarks. Most states do not.
- Carriers can offer benefits above the EHB benchmark but cannot go below it and remain compliant.
- State mandates that exceed EHB create a split premium: APTC covers EHB-equivalent cost; the enrollee or state covers the rest.
- Habilitative services show the widest state-to-state variation in scope, visit limits, and covered conditions.
How the benchmark system works
ACA Section 1302 required HHS to define essential health benefits and delegate the specifics to states. In 2013, HHS gave each state a menu of ten eligible benchmark plan types: the largest small-group plan in the state, several federal employee health plan options, a state employee plan, a commercial HMO, and others. States selected from that menu, and that selection became the coverage template for every QHP sold in the state.
A 2020 HHS rule gave states additional flexibility to construct their benchmark from components of any state's approved list. Most states retained their original benchmark rather than go through the rebenchmarking process with CMS. The result is that coverage floors reflect 2012 and 2013 plan designs, updated incrementally by individual states over the years since.
The benchmark defines the floor, not the ceiling. Carriers can offer benefits above it. What they cannot do is go below it in a plan filed as ACA-compliant.
Where coverage actually differs
The ten EHB category headings are consistent nationwide. "Mental health and substance use disorder services" and "rehabilitative and habilitative services" appear in every state's benchmark. The divergence is in which specific services get counted within each category and whether there are visit limits, prior authorization requirements baked into the benchmark, or excluded diagnoses.
| Benefit area | States with EHB coverage (examples) | Coverage gap states (examples) |
|---|---|---|
| Infertility treatment | IL, MT, RI, CT, NJ, NY | TX, FL, GA, most states |
| Bariatric surgery | Several northeastern states; some midwestern benchmarks | Majority of states; often available only as a plan rider |
| Habilitative services (scope) | Broader: WA, MN, CO, MA | Narrower scope or visit caps in many southern and plains states |
| ASD therapy (visit limits) | Nearly all states cover; limit varies from 30 to unlimited visits | Benchmark differences affect annual cap, not coverage itself |
Illustrative examples based on publicly filed benchmark selections. Carrier plan documents govern actual coverage scope. Verify with the state exchange and the carrier Summary of Benefits and Coverage before relying on this table for a client recommendation.
Habilitative services: the most variable category
Habilitative services, defined broadly as therapies that help a person develop or maintain functional skills (as opposed to rehabilitative services, which restore function after injury or illness), remain the most inconsistent EHB category across states. Some benchmarks require parity between habilitative and rehabilitative coverage without specifying which habilitative services are covered. Others set explicit visit limits that diverge sharply from neighboring states.
CMS issued guidance requiring carriers to cover habilitative services at parity with rehabilitative services for similar conditions. It did not standardize which services count as habilitative. A child with a developmental condition may have access to significantly more covered therapy visits in Washington than in a neighboring state with a narrower benchmark, even if both plans are Bronze tier.
State mandates above EHB and the premium split
Many states have insurance mandates that exceed the EHB benchmark. When a state requires QHPs to cover something beyond EHB, the ACA requires the state or the enrollee to fund the incremental cost. Federal APTC cannot subsidize benefits that exceed EHB.
In plan documents, this shows up as a total premium slightly above the APTC-eligible benchmark premium. Quotit's plan comparison display, like most quoting tools, shows the full premium and the APTC-eligible amount separately when this split applies. Brokers in states with active mandates should be ready to explain why a client's APTC does not cover the entire premium even when the household income would otherwise support full subsidy eligibility.
When benchmark differences change the broker recommendation
For most ACA enrollments, benchmark differences do not change the plan recommendation. A client selecting by premium and deductible is unlikely to notice that their state's benchmark includes infertility treatment. Three situations where the difference matters:
- Relocation and the change-of-residence SEP. A client who moves from Illinois to Texas mid-year, loses prior coverage, and qualifies for a SEP is moving to a different benchmark. Infertility treatment, if ongoing, may no longer be covered under EHB in the new state. The AOR transfer process handles the enrollment mechanics, but the benefit comparison falls to the broker. See QHP certification requirements for how carriers document their benefit filing against the state benchmark.
- Clients with conditions in variable EHB categories. A client managing a condition that relies on habilitative therapy, bariatric surgery, or infertility treatment needs a plan document review, not just a premium comparison. The SBC's covered services section, not the metal tier label, tells you whether the service is covered.
- Cross-state employer comparisons. Employers evaluating group versus individual market options for employees in multiple states sometimes find that the individual market benchmark in one state covers services the group plan does not in another. The standardized plan options address cost-sharing consistency. They do not standardize the benchmark coverage floor.
The ACA deductible limit for EHB-covered services and the out-of-pocket maximum apply consistently across states. The coverage floor does not. Confirm subsidy eligibility with the ACA subsidy calculator first, then review the SBC for any benefit that the client is relying on.
EHB benchmark plan FAQ
Common questions from brokers about how state benchmark selections affect QHP coverage and plan recommendations.
What is an EHB benchmark plan?
An EHB benchmark plan is the state-designated reference plan that establishes the minimum coverage floor for ACA Qualified Health Plans sold in that state. Under ACA Section 1302, HHS required each state to select a benchmark from one of ten eligible plan types established in 2013. Carriers must cover at least the same categories and services as that benchmark. States can update their benchmark through a CMS approval process, though most have retained their original selection.
Do all states use the same EHB benchmark?
No. Each state selected its own benchmark plan, and the resulting coverage floors differ materially. The ten EHB category headings are consistent across states (ambulatory, emergency, hospitalization, maternity, mental health, prescription drugs, rehabilitative, laboratory, preventive, pediatric). What varies is which specific services count within each category. Infertility coverage, bariatric surgery, and the scope of habilitative services are common points of difference.
Can a state add benefits beyond the standard EHB categories?
Yes, and many do. When a state mandates a benefit that exceeds the EHB benchmark, federal subsidies cannot pay for that incremental coverage. The extra cost is either funded by the state directly or billed to the enrollee as an additional premium component. This is why some QHP plan documents show a total premium slightly above the APTC-eligible premium amount.
Does EHB require adult dental or vision coverage?
No. Pediatric dental and vision are required EHB categories. Adult dental and routine vision are not EHB. They may be offered as optional riders or separate dental plans sold alongside the QHP, but the core Qualified Health Plan is not required to cover them for adults.
How do EHB benchmark differences affect clients who move between states?
A client who relocates and triggers a change-of-residence SEP is enrolling in a plan governed by a different state benchmark. A Silver plan in the new state may cover services the prior state's Silver plan did not, or vice versa. Brokers handling AOR transfers for relocated clients should review the Summary of Benefits and Coverage documents in both states before recommending a plan, particularly for clients managing a condition that falls into a variable EHB category.
