(a) Provision of EHB means that a health plan provides benefits that--
(1) Are substantially equal to the EHB-benchmark plan including:
(i) Covered benefits;
(ii) Limitations on coverage including coverage of benefit amount, duration, and scope; and
(iii) Prescription drug benefits that meet the requirements of Sec. 156.122 of this subpart;
(2) With the exception of the EHB category of coverage for pediatric services, do not exclude an enrollee from coverage in an EHB category.
(3) With respect to the mental health and substance use disorder services, including behavioral health treatment services, required under Sec. 156.110(a)(5) of this subpart, comply with the requirements of Sec. 146.136 of this subchapter.
(4) Include preventive health services described in Sec. 147.130 of this subchapter.
(5) If the EHB-benchmark plan does not include coverage for habilitative services, as described in Sec. 156.110(f) of this subpart, include habilitative services in a manner that meets one of the following--
(i) Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings;
(ii) Do not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices; and
(iii) For plan years beginning on or after January 1, 2017, do not impose combined limits on habilitative and rehabilitative services and devices.
(6) For plan years beginning on or after January 1, 2016, for pediatric services that are required under Sec. 156.110(a)(10), provide coverage for enrollees until at least the end of the month in which the enrollee turns 19 years of age.
(b) Unless prohibited by applicable State requirements, an issuer of a plan offering EHB may substitute benefits if the issuer meets the following conditions--
(1) Substitutes a benefit that:
(i) Is actuarially equivalent to the benefit that is being replaced as determined in paragraph (b)(2) of this section;
(ii) Is made only within the same essential health benefit category; and
(iii) Is not a prescription drug benefit.
(2) Submits evidence of actuarial equivalence that is:
(i) Certified by a member of the American Academy of Actuaries;
(ii) Based on an analysis performed in accordance with generally accepted actuarial principles and methodologies;
(iii) Based on a standardized plan population; and
(iv) Determined regardless of cost-sharing.
(c) A health plan does not fail to provide EHB solely because it does not offer the services described in Sec. 156.280(d) of this subchapter.
(d) An issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, or non-medically necessary orthodontia as EHB. [78 FR 12866, Feb. 25, 2013, as amended at 80 FR 10871, Feb. 27, 2015]