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Benchmark Plan Design

Updated 03/12/2020

Frequently Asked Questions

  • The Michigan Benchmark plan requires a minimum of 30 visits for PT/OT combined and 30 visits for ST. All ACA plans must meet this minimum. The visit limits must be separate for PT/OT and ST. Issuers may not impose limits on coverage of habilitative services and devices that are less favorable than limits imposed on coverage of rehabilitative services and devices. Beginning on or after January 1, 2017, combining limits for habilitative and rehabilitative services and devices will not be permitted.

  • No. In Michigan, actuarially equivalent substitutions are not allowed across or within benefit categories.

  • No, a carrier may not refuse to cover a service as long as the service is provided by a health care provider who is acting within the scope of his or her license or certification. With respect to participation under the plan or coverage, under Section 2706(a) of the Public Health Service Act (PHSA), and supported by 45 CFR 147.138, issuers may not discriminate against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law.

  • Yes, but they must be submitted separately for review and approval to the Department of Insurance and Financial Services (DIFS) prior to associating them with QHPs on the Marketplace. Wellness programs, in particular, will be reviewed in light of applicable federal regulations, specifically, 45 CFR Parts 146 and 147, 29 CFR Part 2590, and 26 CFR Part 54.

  • Yes, under current federal guidance, a QHP may include different cost-sharing requirements for out-of-network, non-emergent services.

  • Yes, QHP issuers must submit a zero cost-sharing plan for every level of coverage the issuer is offering. HHS has confirmed that partnership states like Michigan do not have flexibility in variations in the cost-sharing requirements.  Section 155.1030(a) requires State Partnership Marketplaces to ensure that QHP issuers submit the required plan variations, and certify that the plan variations meet the plan design requirements detailed in 45 CFR 156.420. These plan variations include:

    • Three silver plan variations for each silver plan;
    • Zero cost-sharing plan variation for each metal level QHP; and
    • Limited cost-sharing plan variation for each metal level QHP.

    HHS will determine an applicant’s eligibility for cost-sharing reductions and assign them to the appropriate plan variation.  For additional information see CCIIO’s webinar entitled “Marketplace Functions Related to Cost-Sharing Reductions and Advance Payments of the Premium Tax Credit” available at

  • Michigan will continue to define family per MCL 500.3402(3), except that dependent children may be covered up to age 26 (i.e., age 19 was preempted by PPACA).

  • Reasonable medical management techniques are permitted under Section 2713 of the Public Health Services Act (PHSA) and may be used to determine the frequency, method, treatment, or setting, for an item or service unless those items are specified in a state or federal recommendation, guideline or law. As an example, women’s preventive services may be scheduled by a provider in a single visit. Other examples would be the use of step-therapy for prescription benefits or requiring a generic drug instead of a name brand drug.

  • Issuers may offer less comprehensive plans off the Marketplace. In both markets, the ACA requires all non-grandfathered individual and small group plans to include the essential health benefits package. However, a key difference is that to participate in the Marketplace, an insurer must offer at least one silver plan (70% actuarial value) and one gold plan (80% actuarial value). The ACA does not apply this requirement to the outside market, meaning that insurers that do not offer coverage in the Marketplace can provide less comprehensive plans compared to those operating within the Marketplace. The premium for qualified health plans sold off the Marketplace must be the same as the premium of an equal plan sold on the Marketplace whether the plan is offered directly from the issuer or through an agent. Non-grandfathered plans inside and outside the Marketplace must use the same rating factor limitations on age, geography, family size, and tobacco use.

  • No, QHP issuers are not required to adopt particular hour/minute definitions. The hour/minute specifications are merely guidelines for determining the particular benefit, in lieu of imposing strict limitations or exclusions on those benefits. QHP issuers should ensure that any limitations they adopt that differ from the benchmark guidelines do not amount to an exclusion of a required benefit or to a deviation from the scope or duration of benefit limits (e.g., those applicable to physical therapy/speech therapy/occupational therapy). In addition, all QHPs must offer mental health, behavioral health, and substance abuse coverage subject to federal parity laws. Mental health parity under federal law generally requires that such benefits may not be subject to limits that are more stringent than those imposed on medical-surgical benefits. DIFS will review QHPs to assure parity exists between medical benefits and mental, behavioral, and substance abuse benefits.

  • No. The requirement to offer at least one plan in each AV silver and gold level applies to QHP issuers, not to individual plans.

  • Any EHB/Benchmark services offered, even in excess of minimums of the benchmark, are considered EHB services and apply to the index rate and must be spread evenly across the risk pool. See 45 CFR 156.115(a)(1) and the preamble discussion at 78 FR 12843 regarding §156.115.

  • Yes, plan variations “off the Marketplace” must meet actuarial vales at one of the metal levels in the individual and small group markets.

  • Yes, the out-of-pocket maximums will still apply to large group, non-grandfathered plans. The out-of-pocket maximum is revised each year and published by CMS.
  • Yes, the Supreme Court wrote in its decision that the Fourteenth Amendment requires states to recognize same-sex marriages validly performed out-of-state.  “Since same-sex couples may now exercise the fundamental right to marry in all states, there is no lawful basis for a state to refuse to recognize a lawful same-sex marriage performed in another state on the ground of its same-sex character,” the ruling stated.  As Michigan must recognize the marriage, so must the health insurers for purposes of adding a dependent to the insurance policy according to standard policies and procedures for adding dependents. 

  • Yes, eliminating domestic partner coverage fits within the uniform modification exception to the guaranteed renewability rules if the change is made only at plan renewal without consideration of health status, and all domestic partner coverage is eliminated (i.e., opposite-sex couples as well as same-sex couples).

  • Yes, eliminating domestic partner coverage is allowed if all domestic partner coverage is eliminated. Nothing in ERISA prohibits an employer from defining for purposes of plan eligibility, a dependent spouse or domestic partner.

The answers provided are not meant to be a substitute for legal advice.