ACA Benchmark Plan: Ten Required Benefits and How States Choose

An ACA benchmark plan is a real health insurance policy that each state picks to serve as the coverage template for every non-grandfathered plan sold in its individual and small group markets. Federal law requires those plans to cover ten broad categories of care called essential health benefits, but a category like “hospitalization” or “prescription drugs” is too vague on its own. The benchmark fills in the specifics: how many physical therapy visits are covered, which drug classes must appear on the formulary, what limits apply. Insurers can offer more than the benchmark. They cannot offer less.

What the Benchmark Actually Does

Think of the benchmark as a floor written in concrete terms. Actuaries compare every plan on the marketplace against it and certify that the benefits are substantially equal before the plan can be sold. That certification is what stops insurers from technically checking the ten-category box while gutting the coverage inside each one.

Federal rules also block insurers from designing benefits in ways that discourage people with particular health conditions from enrolling. A plan does not qualify as providing essential health benefits if its design discriminates based on age, disability, expected length of life, medical dependency, or other health conditions. Benefit designs must be clinically based. Insurers can still use reasonable medical management tools like prior authorization.

The Ten Required Benefit Categories

Every benchmark plan has to include all ten of the categories set out in federal law.¹ The state controls the scope inside each one, but no category can be dropped.

Ambulatory patient services: outpatient care like doctor visits and same-day surgery.
Emergency services: emergency room care, which insurers must cover without prior authorization.
Hospitalization: inpatient stays for surgery, recovery, and other overnight treatment.
Maternity and newborn care: prenatal visits, labor, delivery, and postpartum care for parent and child.
Mental health and substance use disorder services: behavioral health treatment, therapy, and addiction services.
Prescription drugs: medication coverage meeting minimum formulary requirements.
Rehabilitative and habilitative services: services and devices that help people recover skills after an injury or develop skills they never had due to a disability or chronic condition.
Laboratory services: blood work, diagnostic imaging, and other tests.
Preventive and wellness services: screenings, vaccines, and chronic disease management.
Pediatric services: medical, dental, and vision care for children.

Three of these categories carry extra federal rules that override whatever the state’s benchmark otherwise says.

Prescription Drug Formularies and Exceptions

A plan meets the prescription drug requirement only if its formulary covers at least one drug in every United States Pharmacopeia category and class, or matches the number of drugs the state’s benchmark covers in each category, whichever is greater. Plans must also let you request coverage for a drug that isn’t on the formulary through a formal exception process. Standard requests get a decision within 72 hours. If your health could be jeopardized or an ongoing course of treatment interrupted, an expedited review must produce a decision within 24 hours. When a standard exception is granted, the insurer has to cover the drug for the full duration of the prescription, including refills.²

Preventive Care at No Cost

Most non-grandfathered plans must cover certain preventive services in-network with no copay, coinsurance, or deductible. The covered list comes from four sources: items rated A or B by the U.S. Preventive Services Task Force, routine immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, preventive care guidelines for children supported by the Health Resources and Services Administration, and women’s preventive care and screenings supported by HRSA.³

Mental Health Parity

Mental health and substance use disorder benefits carry their own enforcement layer under the Mental Health Parity and Addiction Equity Act. Insurers cannot impose treatment limitations on behavioral health benefits that are more restrictive than those applied to comparable medical and surgical benefits. For plan years beginning on or after January 1, 2026, updated federal rules require plans to collect data measuring whether their non-quantitative treatment limitations create material differences in access to behavioral health services compared with physical health services, and to take corrective action if they do.⁴

Pediatric Dental and Vision

Pediatric dental and vision benefits must be covered at least until the end of the month in which the enrollee turns 19. States can extend that upward but not below. These pediatric benefits can be delivered through the medical plan or through a stand-alone dental plan sold alongside it.

Which Plans Have to Follow Benchmark Rules

The benchmark reaches two markets: individual coverage (plans you buy on your own, including through the ACA marketplace) and small group coverage (employer plans for businesses that generally have 50 or fewer employees).⁵ Several major kinds of coverage sit outside those rules entirely.

Large group plans (employers with more than 50 employees) are not required to offer essential health benefits, though if they do cover them, they cannot impose annual or lifetime dollar limits on those services.⁶
Self-insured employer plans, where the employer pays claims directly instead of buying insurance from a carrier, are also not required to provide essential health benefits. The same rule on dollar caps applies.⁶
Grandfathered plans, meaning plans that existed on March 23, 2010 and have not made certain significant changes to cost-sharing or benefit structure, are exempt from the essential health benefits mandate.⁷
Excepted benefits such as accident-only policies, disability income insurance, workers’ compensation, fixed indemnity hospital plans, limited-scope dental or vision plans, and long-term care insurance sit outside the requirements entirely.⁸

If you’re on a large employer plan or a self-insured plan, your coverage may look similar to a benchmarked plan, but your employer isn’t legally required to match the state’s list. That gap matters most when you’re comparing an employer offer against a marketplace plan.

How a State’s Benchmark Gets Set

Every state made an initial benchmark selection when the ACA took effect, choosing from a menu of large small group plans, state or federal employee plans, or the largest commercial HMO in the state.⁹ Most ended up with a small group plan. Many states still use that original selection.

Starting with the 2020 plan year, states gained flexibility to change their benchmark.¹⁰ As of the 2026 plan year, twelve jurisdictions have updated their benchmarks since that option opened, including Illinois, Colorado, Oregon, Alaska, and the District of Columbia.⁵

The Scope Test

For plan year 2026 and beyond, a state changing its benchmark selects a new set of benefits that must pass a scope-of-benefits test. The new plan’s coverage has to be equal to a typical employer plan in the state, meaning it cannot be less generous than the least generous comparison plan and cannot exceed the most generous.¹⁰ The comparison set now pulls from two pools: the state’s original 2017 benchmark options and the largest plan in each of the five largest large group products in the state. Benefits cannot be unduly weighted toward any single category, and the plan must serve diverse populations including women, children, and people with disabilities.

Deadlines and Public Comment

States submit proposed changes to HHS by the first Wednesday in May of the year that falls two years before the plan year takes effect. A change for 2028 has to be filed by the first Wednesday in May 2026. Miss the deadline or file something that doesn’t meet federal requirements, and the prior year’s benchmark carries forward automatically.¹⁰ Before submitting, the state must provide reasonable public notice and an opportunity to comment, including posting the notice on a relevant state website. Federal rules do not set a minimum comment period, so length and format vary.

When States Add Benefits Beyond the Benchmark

States often require insurers to cover services that go beyond the benchmark, like fertility treatments or hearing aids. If the mandate was enacted on or before December 31, 2011, it folds into the essential health benefits package at no extra cost to the state. Anything mandated after that triggers defrayal: the state itself has to pay for the added cost, either directly to insurers or by reimbursing enrollees.¹¹ Each insurer calculates the extra cost attributable to the mandate through an actuarial analysis and reports it to the state.¹² Some states have folded popular mandates into an updated benchmark instead of paying defrayal indefinitely.

If a Plan Isn’t Following the Rules

States are the primary enforcers of insurance market rules, including essential health benefits. When a state falls short, the federal government has backup authority: if the Secretary of HHS determines a state has failed to substantially enforce the provisions, the federal government enforces them directly against insurers in that state.¹³ CMS can open a review based on consumer complaints, news reports, or periodic examinations of state legislation.¹⁴ If your plan isn’t covering something you believe the benchmark requires, complaints usually start with your state insurance department; a formal exception request, especially for a drug, has enforceable deadlines the insurer must meet.

1
Office of the Law Revision Counsel. 42 USC 18022 – Essential Health Benefits Requirements
2
eCFR. 45 CFR 156.122 – Prescription Drug Benefits
3
Centers for Medicare & Medicaid Services. Affordable Care Act Implementation FAQs – Set 12
4
Federal Register. Requirements Related to the Mental Health Parity and Addiction Equity Act
5
Centers for Medicare & Medicaid Services. Information on Essential Health Benefits Benchmark Plans
6
U.S. Department of Labor. FAQs About Affordable Care Act Implementation Part 66
7
Office of the Law Revision Counsel. 42 USC 18011 – Preservation of Right to Maintain Existing Coverage
8
eCFR. 45 CFR 148.220 – Excepted Benefits
9
eCFR. 45 CFR 156.100 – State Selection of Benchmark Plan for Plan Years Beginning Prior to January 1, 2020
10
eCFR. 45 CFR 156.111 – State Selection of EHB-Benchmark Plan for Plan Years Beginning on or After January 1, 2020
11
Centers for Medicare & Medicaid Services. Frequently Asked Questions on Defrayal of State Additional Required Benefits
12
eCFR. 45 CFR 155.170 – Additional Required Benefits
13
Office of the Law Revision Counsel. 42 USC 300gg-22 – Enforcement
14
eCFR. 45 CFR Part 150 – CMS Enforcement in Group and Individual Insurance Markets