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Essential Health Benefits (EHB)

On September 30, 2012, the state of Illinois submitted our recommendation for the Essential Health Benefits benchmark plan to the Department of Health and Human Services. The benchmark plan, BlueCross BlueShield BlueAdvantage, will provide the baseline for services provided in Qualified Health Plans sold inside and outside of the Illinois Exchange beginning in January 2014. You can view a detailed description on the services provided in the BlueAdvantage plan here. The full benefit booklet is available here.

Federal Comment Period

The Department of Health and Human Services recently released a proposed rule on the Essential Health Benefits. A fact sheet is available here. HHS will hold a comment period until December 26, 2012. Detailed instructions for submitting comments are included in the proposed rule which can be found here.


In August 2012, the Governor’s Office convened a workgroup of representatives from a number of state agencies to develop a recommendation to the Healthcare Reform Implementation Council on Essential Health Benefits (EHBs) for qualified health plans in Illinois. This Workgroup met several times over the course of two months.

The Affordable Care Act defined ten Essential Health Benefits (EHB) that must be included in all Qualified Health Plans sold inside and outside the Health Benefits Exchange starting in 2014.

The ten categories of benefits are: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.

The purpose of recommending a benchmark plan is to ensure that individuals who purchase health insurance will have a plan that covers the essential health benefits and services outlined by the ACA. 

The United States Department of Health and Human Services (HHS) set specific guidelines to establish EHB. HHS requires that states look at the insurance plans already sold in their markets and identify a ‘benchmark’ plan that is representative of a ‘typical employer plan’. This will help ensure that state insurance mandates are included, since any benchmark plan must already be available in a state.

The authority to select a benchmark plan falls with the HHS Secretary, but the state is required to make a recommendation. HHS will also facilitate a public comment period on the benchmark plan that the state recommends.

The Workgroup recommends the BlueCross BlueShield of Illinois BlueAdvantage small group plan as Illinois’ EHB benchmark plan. The Workgroup also recommends that the pediatric dental and vision categories are supplemented with FEDVIP BlueVision vision package and the state AllKids dental package. Because none of the potential benchmark plans included sufficient coverage in these areas, the state is required to supplement the plans using options specified by the federal government.  

It is important to note that although we are choosing a specific benchmark plan, it is the services that are provided by this particular plan that will make up the Essential Health Benefits for Illinois. This does not mean that only BCBS will be represented in the marketplace; it means that all insurers that sell products inside and outside the Exchange will be required to include, at a minimum, the value of benefits and services dictated by the benchmark plan in their own plans.

The Health Care Reform Implementation Council intends to continuously review the benchmark selection over the next two years, at which point the state might have the option to change or amend our benchmark plan. The Council envisions an open process for feedback that engages stakeholders and ensures the minimum coverage offered in Illinois meets the needs of our residents.