https://www.insurerbrain.com/w/index.php?action=history&feed=atom&title=Definition%3ABenchmark_planDefinition:Benchmark plan - Revision history2026-06-14T02:43:16ZRevision history for this page on the wikiMediaWiki 1.43.8https://www.insurerbrain.com/w/index.php?title=Definition:Benchmark_plan&diff=8578&oldid=prevPlumBot: Bot: Creating new article from JSON2026-03-11T04:21:34Z<p>Bot: Creating new article from JSON</p>
<p><b>New page</b></p><div>🏥 '''Benchmark plan''' is a reference [[Definition:Health insurance | health insurance]] plan selected by a state — or defaulted to by federal methodology — that defines the minimum [[Definition:Essential health benefits (EHB) | essential health benefits]] package all individual and small-group [[Definition:Health insurance plan | plans]] sold in that state must cover under the [[Definition:Affordable Care Act (ACA) | Affordable Care Act]]. Rather than prescribing a uniform federal benefits list, the ACA framework allows each state to choose a benchmark from among a set of existing plan designs — typically the largest small-group plan by enrollment, one of the three largest state employee plans, one of the three largest federal employee plans, or the largest commercial [[Definition:Health maintenance organization (HMO) | HMO]] — thereby anchoring benefit mandates to real-world coverage already in the market.<br />
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📋 Once a state selects its benchmark, every [[Definition:Qualified health plan (QHP) | qualified health plan]] offered through the state's [[Definition:Health insurance marketplace | marketplace]] or in the off-exchange individual and small-group markets must provide coverage that is "substantially equal" to the benchmark across ten statutory [[Definition:Essential health benefits (EHB) | EHB]] categories, including hospitalization, prescription drugs, maternity care, and mental health services. If the chosen benchmark lacks coverage in a required category — for example, pediatric dental — the state supplements it from another reference plan. [[Definition:Insurance carrier | Carriers]] designing products must map their [[Definition:Benefit design | benefit structures]], [[Definition:Cost-sharing | cost-sharing]] levels, and [[Definition:Formulary | formularies]] against the benchmark to ensure compliance, a process that directly influences [[Definition:Actuarial value | actuarial value]] calculations and [[Definition:Rate filing | rate filings]] submitted to state [[Definition:Insurance regulator | regulators]].<br />
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🔍 The benchmark plan matters enormously because it determines the practical scope of what "comprehensive coverage" means in a given state — and those scopes vary. A state whose benchmark includes generous [[Definition:Prescription drug coverage | prescription drug]] tiers effectively mandates richer pharmacy benefits for all individual and small-group insurers operating there, raising [[Definition:Premium | premiums]] but broadening access. Conversely, a leaner benchmark can keep premiums lower at the cost of narrower coverage. For carriers entering new state markets, analyzing the benchmark is one of the first steps in [[Definition:Product development | product development]], because it sets the floor below which no compliant plan can fall. The selection also has downstream effects on [[Definition:Reinsurance | reinsurance]] pricing and [[Definition:Risk adjustment | risk adjustment]] transfer calculations that shape carrier profitability.<br />
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'''Related concepts:'''<br />
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* [[Definition:Essential health benefits (EHB)]]<br />
* [[Definition:Affordable Care Act (ACA)]]<br />
* [[Definition:Qualified health plan (QHP)]]<br />
* [[Definition:Actuarial value]]<br />
* [[Definition:Health insurance marketplace]]<br />
* [[Definition:Benefit design]]<br />
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