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{"sheet":"State's EHB Confirmations","index":0,"n_rows":45,"n_cols":3,"rows_kept":45,"cut":false,"hidden":false,"merged":[]}
["Confirmations on the State EHB-benchmark Plan ",null,"OMB Control Number: 0938-1174\nExpiration Date: 02/28/2024"]
["Instructions: All fields on this template are required to be completed. Please make sure to answer all fields and confirm that the new EHB-benchmark Plan covers all 10 EHB categories: (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. Under Section D, please complete the \"Explanation\" column with sentences describing how the State is complying with the specific requirement; single word responses such as Yes, No, or N/A are not sufficient responses."]
["SECTION A"]
["Points of Contact for the State's EHB- benchmark Plan Selection","Primary","Secondary"]
["Name","Jane Beyer","Ned Gaines"]
["Agency","Washington Office of the Insurance Commissioner","Washington Office of the Insurance Commissioner"]
["Phone Number","360-725-7043","360-725-7126"]
["Email","Jane.Beyer@oic.wa.gov","Ned.Gaines@oic.wa.gov"]
["SECTION B"]
["EHB-Benchmark Plan Selection Options","State's Selections"]
["State","Washington"]
["Under which option of 45 CFR 156.111(a), is the State selecting its new EHB-benchmark Plan?","§156.111(a)(3) ‐ Select a set of benefits that would become theState’s EHB‐benchmark plan"]
["For what plan year is the State selecting its new EHB-benchmark Plan to begin applying?","Plan Year 2026"]
["If using §156.111(a)(1), which other State's EHB-benchmark Plan is the State using for its EHB-benchmark plan?","Not Applicable to State's Selection Option"]
["SECTION C"]
["EHB Category Criteria for a State EHB-benchmark Plan at 45 CFR 156.111","Does the State's EHB-benchmark Plan cover the category?"," If the State's is using §156.111(a)(2), select the other State's EHB-benchmark Plan being used for the particular category"]
["Ambulatory patient services","Yes","Not Applicable to State's Selection Option"]
["Emergency services","Yes","Not Applicable to State's Selection Option"]
["Hospitalization","Yes","Not Applicable to State's Selection Option"]
["Maternity and newborn care","Yes","Not Applicable to State's Selection Option"]
["Mental health and substance use disorder services, including behavioral health treatment","Yes","Not Applicable to State's Selection Option"]
["Prescription drugs*","Yes","Not Applicable to State's Selection Option"]
["If the State is using the option under §156.111(a)(3), did the State provide a complete and accurate formulary drug list under the Appendix D entitled “Rx Template” in this workbook?","Yes","Not Applicable to State's Selection Option"]
["Rehabilitative and habilitative services and devices","Yes","Not Applicable to State's Selection Option"]
["Laboratory services","Yes","Not Applicable to State's Selection Option"]
["Preventative, wellness, and chronic disease management","Yes","Not Applicable to State's Selection Option"]
["Pediatric services, including oral and vision care","Yes","Not Applicable to State's Selection Option"]
["* Note: Due to the availability of drugs in the market, the exact drug count for a given State will be established in the EHB drug count tool, but for the purposes of the State's EHB- benchmark Plan, the display will be the same drug count as the 2017 EHB-benchmark plan. "]
["SECTION D"]
["Under Section D, please complete the \"Explanation\" column with sentences describing how the State is complying with the specific requirement; single word responses such as Yes, No, or N/A are not sufficient responses."]
["EHB-Benchmark Plan Requirements","State's Confirmations","Explanation"]
["Does the State's EHB-benchmark Plan definition meet the requirements of §156.111(b)(1) with regard to scope of benefits?","Yes","Wakely has determined that the proposed EHB-benchmark plan meets the requirements of 156.111 (b)(1) with regard to scope of benefits."]
["Is the State's EHB-benchmark Plan equal to, or greater than, to the extent any supplementation is required to provide coverage within each EHB category at §156.110(a), the scope of benefits provided under a typical employer plan as defined and established at  §156.111(b)(2)(i)?","Yes","Wakely has determined that the proposed EHB‐benchmark plan is equal to or greater than the scope of benefits provided under a typical employer plan."]
["Has an actuary, who is a member of the American Academy of Actuaries, in accordance with generally accepted actuarial principles and methodologies, affirmed that the State's new EHB-benchmark plan provides a scope of benefits that is equal to, or greater than, to the extent any supplementation is required to provide coverage within each EHB category at §156.110(a), to the scope of benefits provided under a typical employer plan as defined at §156.111(b)(2)(i) and in accordance with §156.111(e)(2)?","Yes","Wakely has affirmed that the State's new EHB‐benchmark plan provides a scope of benefits that is equal to the scope of benefits provided under a typical employer plan and in accordance with 156.111 (e) (2)"]
["Does the State's EHB-benchmark Plan not exceed the generosity of the most generous the plans listed at §156.111(b)(2)(ii) ?","Yes","Wakely has determined that the State's EHB‐benchmark plan does not exceed the generosity of the most generous plans listed at 156.111 (b) (2) (ii)"]
["Has an actuary, who is a member of the American Academy of Actuaries, in accordance with generally accepted actuarial principles and methodologies, affirmed that the new EHB-benchmark plan does not exceed the generosity of the most generous the plans listed at §156.111(b)(2)(ii) and in accordance with §156.111(e)(2)?","Yes","Yes, Wakely has affirmed that the new EHB‐benchmark plan does not exceed the generosity of the most generous the plans listed at §156.111(b)(2)(ii) and in accordance with §156.111(e)(2)?"]
["Is the State's EHB-benchmark Plan unduly weighting benefits towards any of the categories of benefits (§156.111(b)(2)(iii))?","No","No, the State's EHB-benchmark Plan is not unduly weighting benefits towards any of the categories of benefits (§156.111(b)(2)(iii))"]
["Does the State's EHB-benchmark Plan provide benefits for diverse segments of the population in accordance with §156.111(b)(2)(iv)?","Yes","Yes, the State's EHB-benchmark plan provides benefits for diverse segments of the population in accordance with §156.111(b)(2)(iv)"]
["Did the State provide reasonable public notice and an opportunity for public comment on the State's selection of its EHB-benchmark Plan that includes posting a notice on its opportunity for public comment with associated information on a relevant State Web site in accordance with §156.111(c)? Please provide the public notice dates and applicable website address in the \"Explanation\" column.","Yes","Public comment period held X-Y dates."]
["Are non-EHB benefits excluded from the EHB-benchmark Plan in accordance with §156.115(d)? (Non-EHB benefits include adult vision, adult dental, long-term care, cosmetic orthodontia)","Yes","Yes, non-EHB benefits are excluded from the EHB-benchmark plan in accordance with 156.115(d)"]
["Has the State converted any benefits in its EHB-benchmark Plan restricted by annual or lifetime dollar limits as defined by §147.126 to non-dollar limit benefits?","No","No, the state has not converted any benefits in its EHB-benchmark plan restricted by annual or lifetime dollar limits to non-dollar limit benefits."]
["Does the EHB-benchmark Plan include benefits mandated by State action taking place after 2011, other than for purposes of compliance with Federal requirements, for which payment is required under §155.170?","No","No, the State's EHB-benchmark plan does not include benefits mandated after 2011 other than for the purposes of compliance with Federal requirements."]
["Are the EHB-benchmark Plan's benefits designed such that they do not discriminate based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions as prohibited by §156.125 and in accordance with §156.111(b)(2)(v)? ","Yes","Yes, the EHB-benchmark plan benefits are designed such that they do not discriminate based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions as prohibited by §156.125 and in accordance with §156.111(b)(2)(v)"]
["Is there any additional information CMS should know?","No","See Wakely report and analysis."]
["PRA Disclosure Statement\nAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1174 (Expires 02/28/2024). The time required to complete this information collection is estimated to average 47 hours or 2,820 minutes per response for States. For Form 1, the estimate is 4 hours. For Form 2, the estimate is 19 hours. For Form 3, the estimate is 12 hours. For Form 4, the estimate is 12 hours. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. \n\n****CMS Disclosure****\nPlease do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Ken Buerger at Ken.Buerger@cms.hhs.gov. "]

{"sheet":"156.111(a)(1) other states","index":1,"n_rows":53,"n_cols":1,"rows_kept":53,"cut":false,"hidden":true,"merged":[]}
["If using §156.111(a)(1), which other State's EHB-benchmark Plan is the State using for its EHB-benchmark plan?"]
["Not Applicable to State's Selection Option"]
["Alabama"]
["Alaska"]
["Arizona"]
["Arkansas"]
["California"]
["Colorado"]
["Connecticut"]
["Delaware"]
["District of Columbia"]
["Florida"]
["Georgia"]
["Hawaii"]
["Idaho"]
["Illinois"]
["Indiana"]
["Iowa"]
["Kansas"]
["Kentucky"]
["Louisiana"]
["Maine"]
["Maryland"]
["Massachusetts"]
["Michigan"]
["Minnesota"]
["Mississippi"]
["Missouri"]
["Montana"]
["Nebraska"]
["Nevada"]
["New Hampshire"]
["New Jersey"]
["New Mexico"]
["New York"]
["North Carolina"]
["North Dakota"]
["Ohio"]
["Oklahoma"]
["Oregon"]
["Pennsylvania"]
["Rhode Island"]
["South Carolina"]
["South Dakota"]
["Tennessee"]
["Texas"]
["Utah"]
["Vermont"]
["Virginia"]
["Washington"]
["West Virginia"]
["Wisconsin"]
["Wyoming"]

{"sheet":"45 CFR 156.111(a)","index":2,"n_rows":4,"n_cols":1,"rows_kept":4,"cut":false,"hidden":true,"merged":[]}
["Under which option of 45 CFR 156.111(a) is the State selecting its new EHB-benchmark Plan?"]
["§ 156.111(a)(1) – Select the EHB-benchmark plan from another State"]
["§ 156.111(a)(2) - Replace one or more categories of EHBs from another State’s EHB-benchmark plan"]
["§ 156.111(a)(3) - Select a set of benefits that would become the State’s EHB-benchmark plan"]

{"sheet":"Plan Year","index":3,"n_rows":6,"n_cols":1,"rows_kept":6,"cut":false,"hidden":true,"merged":[]}
["For what plan year is the State selecting its new EHB-benchmark Plan to begin applying?"]
["Plan Year 2021"]
["Plan Year 2022"]
["Plan Year 2023"]
["Plan Year 2024"]
["Plan Year 2025"]

{"sheet":"Limit Units","index":4,"n_rows":5,"n_cols":131,"rows_kept":5,"cut":false,"hidden":true,"merged":[]}
[" "," Visit(s) per Year"," Visit(s) per Benefit Period"," Visit(s) per Lifetime"," Visit(s) per Month"," Visit(s) per Episode"," Visit(s) per Stay"," Visit(s) per Transplant"," Visit(s) per 6 Months"," Visit(s) per 2 Years"," Visit(s) per 3 Years"," Visit(s) per Procedure"," Visit(s) per Week"," Visit(s) per Admission"," Dollar(s) per Year"," Dollar(s) per Benefit Period"," Dollar(s) per Lifetime"," Dollar(s) per Month"," Dollar(s) per Episode"," Dollar(s) per Stay"," Dollar(s) per Transplant"," Dollar(s) per 6 Months"," Dollar(s) per 2 Years"," Dollar(s) per 3 Years"," Dollar(s) per Procedure"," Dollar(s) per Week"," Dollar(s) per Admission"," Exam(s) per Year"," Exam(s) per Benefit Period"," Exam(s) per Lifetime"," Exam(s) per Month"," Exam(s) per Episode"," Exam(s) per Stay"," Exam(s) per Transplant"," Exam(s) per 6 Months"," Exam(s) per 2 Years"," Exam(s) per 3 Years"," Exam(s) per Procedure"," Exam(s) per Week"," Exam(s) per Admission"," Day(s) per Year"," Day(s) per Benefit Period"," Day(s) per Lifetime"," Day(s) per Month"," Day(s) per Episode"," Day(s) per Stay"," Day(s) per Transplant"," Day(s) per 6 Months"," Day(s) per 2 Years"," Day(s) per 3 Years"," Day(s) per Procedure"," Day(s) per Week"," Day(s) per Admission"," Item(s) per Year"," Item(s) per Benefit Period"," Item(s) per Lifetime"," Item(s) per Month"," Item(s) per Episode"," Item(s) per Stay"," Item(s) per Transplant"," Item(s) per 6 Months"," Item(s) per 2 Years"," Item(s) per 3 Years"," Item(s) per Procedure"," Item(s) per Week"," Item(s) per Admission"," Month(s) per Year"," Month(s) per Benefit Period"," Month(s) per Lifetime"," Month(s) per Month"," Month(s) per Episode"," Month(s) per Stay"," Month(s) per Transplant"," Month(s) per 6 Months"," Month(s) per 2 Years"," Month(s) per 3 Years"," Month(s) per Procedure"," Month(s) per Week"," Month(s) per Admission"," Treatment(s) per Year"," Treatment(s) per Benefit Period"," Treatment(s) per Lifetime"," Treatment(s) per Month"," Treatment(s) per Episode"," Treatment(s) per Stay"," Treatment(s) per Transplant"," Treatment(s) per 6 Months"," Treatment(s) per 2 Years"," Treatment(s) per 3 Years"," Treatment(s) per Procedure"," Treatment(s) per Week"," Treatment(s) per Admission"," Procedure(s) per Year"," Procedure(s) per Benefit Period"," Procedure(s) per Lifetime"," Procedure(s) per Month"," Procedure(s) per Episode"," Procedure(s) per Stay"," Procedure(s) per Transplant"," Procedure(s) per 6 Months"," Procedure(s) per 2 Years"," Procedure(s) per 3 Years"," Procedure(s) per Procedure"," Procedure(s) per Week"," Procedure(s) per Admission"," Hour(s) per Year"," Hour(s) per Benefit Period"," Hour(s) per Lifetime"," Hour(s) per Month"," Hour(s) per Episode"," Hour(s) per Stay"," Hour(s) per Transplant"," Hour(s) per 6 Months"," Hour(s) per 2 Years"," Hour(s) per 3 Years"," Hour(s) per Procedure"," Hour(s) per Week"," Hour(s) per Admission"," Admission(s) per Year"," Admission(s) per Benefit Period"," Admission(s) per Lifetime"," Admission(s) per Month"," Admission(s) per Episode"," Admission(s) per Stay"," Admission(s) per Transplant"," Admission(s) per 6 Months"," Admission(s) per 2 Years"," Admission(s) per 3 Years"," Admission(s) per Procedure"," Admission(s) per Week"," Admission(s) per Admission"]
["§ 156.111(a)(1) – Select the EHB-benchmark plan from another State","§ 156.111(a)(2) - Replace one or more categories of EHBs from another State’s EHB-benchmark plan","§ 156.111(a)(3) - Select a set of benefits that would become the State’s EHB-benchmark plan"]
["Not Applicable to State's Selection Option","Alabama","Alaska","Arizona","Arkansas","California","Colorado","Connecticut","Delaware","District of Columbia","Florida","Georgia","Hawaii","Idaho","Illinois","Indiana","Iowa","Kansas","Kentucky","Louisiana","Maine","Maryland","Massachusetts","Michigan","Minnesota","Mississippi","Missouri","Montana","Nebraska","Nevada","New Hampshire","New Jersey","New Mexico","New York","North Carolina","North Dakota","Ohio","Oklahoma","Oregon","Pennsylvania","Rhode Island","South Carolina","South Dakota","Tennessee","Texas","Utah","Vermont","Virginia","Washington","West Virginia","Wisconsin","Wyoming"]
["Plan Year 2019","Plan Year 2020","Plan Year 2021","Plan Year 2022"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable to State's Selection Option","Yes"]