The Essential Health Benefits (EHB) Checklist: What Small Practices Need to Know About Coverage Mandates (45 CFR § 156.105)

Small healthcare practices increasingly encounter coverage questions that turn on the Affordable Care Act’s Essential Health Benefits (EHB) framework. Although the title references 45 CFR 156.105, the day-to-day rules clinics feel most come from 45 CFR 156 Subpart B, especially § 156.110 (EHB-benchmark plan standards) and § 156.115 (Provision of EHB), grounded in 42 U.S.C. § 18022. Understanding these provisions helps front-desk and billing teams anticipate patient eligibility, navigate prior authorization, and resolve denials.

Because state-selected EHB-benchmark plans determine market-wide minimum coverage in the individual and small-group markets, clinics that align ordering and documentation with those benchmarks reduce appeals and uncompensated care. Anti-discrimination, mental health parity, pediatric oral/vision coverage rules, and prescription drug adequacy are particularly high-impact. For small practices, translating EHB legal language into everyday intake, coding, and referral protocols is the practical path to fewer surprises and faster reimbursement.

When a patient asks “Is this covered?” the answer often depends on EHB. In the individual and small-group markets, issuers must cover benefits that are substantially equal to the state’s EHB-benchmark plan. These requirements flow from 42 U.S.C. § 18022 and are implemented in 45 CFR part 156, subpart B. While § 156.105 addresses EHB determinations for multi-state plans, clinics principally interact with the broader framework: the ten EHB categories, benchmark supplementation rules, prescription drug standards, non-discrimination, parity, and pediatric oral/vision elements.

This article translates those provisions into concrete clinic workflows, what to verify at intake, how to structure documentation, and how to escalate denials when plans appear to deviate from EHB standards.

Understanding The Essential Health Benefits EHB Checklist Under 45 CFR 156.105

EHB is a package concept built on statute and regulation. The statute (42 U.S.C. § 18022) defines ten required categories and directs HHS to set guardrails. The regulations in 45 CFR 156 Subpart B operationalize that mandate through state-specific benchmarks and rules that issuers must follow. While § 156.105 speaks to multi-state plan EHB determinations, clinics should anchor operations on four pillars:

1. Categories and Benchmark Standards: An EHB-benchmark plan must include items and services in the ten statutory categories (ambulatory, emergency, hospitalization, maternity/newborn, MH/SUD including behavioral health treatment, prescription drugs, rehabilitative/habilitative services and devices, laboratory, preventive/wellness/chronic disease management, and pediatric services including oral and vision). See § 156.110 and 42 U.S.C. § 18022(b). If a base benchmark lacks a category, it must be supplemented from another permitted plan.

2. Provision of EHB: Plans must be substantially equal to the benchmark in covered benefits and key limitations (amount, duration, scope). Preventive services under § 147.130 must be included; MH/SUD services must comply with parity (PHS Act § 2726). See § 156.115.

3. Prescription Drugs: Formularies must meet minimum adequacy standards; substitution and coverage policies must align with § 156.122 and be nondiscriminatory (§ 156.125).

4. State Flexibility and Updates: States define or update benchmarks (§ 156.111), subject to federal guardrails, actuarial certification, and anti-discrimination. Clinics must expect periodic changes that can affect medical necessity evidence and prior auth.

Grasping this legal framework lets small practices predict how coverage determinations should work, frame appeals against the correct standard, and avoid avoidable write-offs.

The Office for Civil Rights (OCR) enforces HIPAA privacy, security, and breach notification, not EHB benefit design. EHB compliance is principally overseen by HHS/CMS (CCIIO) and state insurance departments, which review issuer filings against 45 CFR 156 and the state’s EHB-benchmark plan. OCR may still matter at your clinic, but for privacy/security issues that can intersect with coverage transactions (for example, minimum necessary disclosures or parity-related PHI). For EHB enforcement, expect oversight from CMS/CCIIO and state regulators, with audits, market conduct exams, and corrective actions tied to benchmark compliance and non-discrimination rules.

1) Verify the patient’s market segment and benchmark context

Role: Front Desk / Eligibility

How to comply:

• At registration, confirm whether the plan is individual/small-group (EHB applies) or large-group/self-funded (different standards).

• Capture the plan year to align with the correct state benchmark selection period under § 156.111.

Evidence:

• Eligibility verification screenshot.

• Plan documents indicating market type and plan year.

Low-cost tip:

• Maintain a one-page internal “State Benchmark Snapshot” for your state, updated annually from CMS/CCIIO public materials.

2) Map the ordered service to an EHB category

Role: Clinician + Coding

How to comply:

• For each common service line (e.g., DME for habilitative needs, outpatient MH therapy), assign the likely EHB category and any benchmark limits (e.g., therapy visit caps).

Evidence:

• Problem-list mapping.

• Plan medical policy excerpts for the EHB category.

• Coding crosswalks.

Low-cost tip:

• Build a shared drive folder with category quick sheets (ten EHB categories, with clinic-specific examples).

3) Document medical necessity to the benchmark standard

Role: Clinician

How to comply:

• Ensure progress notes address criteria issuers reference for “substantially equal” coverage (§ 156.115), including duration and scope.

• For MH/SUD, document parity-consistent rationales (PHS Act § 2726).

Evidence:

• SOAP notes.

• Standardized templates for therapy goals and functional gains (rehab/hab).

Low-cost tip:

• Add a mandatory field in the note template: “EHB category and benchmark criteria addressed.”

4) Check preventive services and cost-sharing

Role: Front Desk / Billing

How to comply:

• For USPSTF A/B services, women’s preventive, and ACIP immunizations, apply the preventive services inclusion requirement cited in § 156.115(a)(4) and § 147.130.

Evidence:

• Encounter form highlighting preventive service.

• Payer preventive grid.

Low-cost tip:

• Keep a laminated “Preventive Quick Grid” at check-in for zero-cost-sharing services.

5) Review drug coverage adequacy and exceptions

Role: Clinician + Billing

How to comply:

• Confirm that the plan’s formulary meets § 156.122 standards.

• When appropriate, initiate exceptions with benchmark-consistent justification.

Evidence:

• Formulary screenshot.

• Prior authorization submission including benchmark rationale.

• Denial letters.

Low-cost tip:

• Maintain a small library of exception letter templates tied to benchmark categories (e.g., anticonvulsant coverage nuances).

6) Guard against discriminatory limits

Role: All Staff

How to comply:

• Screen plan denials and internal scheduling rules for discriminatory patterns that would conflict with § 156.125 (e.g., categorically denying habilitative devices for developmental conditions).

Evidence:

• Denial logs tagged “potential § 156.125”.

• Escalation memos to payer representatives.

Low-cost tip:

• Hold a 15-minute monthly huddle to review one “odd” denial against the non-discrimination rule.

7) Appeal with the right citation

Role: Billing / Administrator

How to comply:

• In first-level appeals, explicitly cite the EHB category and § 156.115 “substantially equal” language.

• For therapy or devices, point to benchmark supplementation logic under § 156.110(b) when plans rely on a base-benchmark that historically omitted a category.

Evidence:

• Appeal letters.

• Attachments of benchmark summaries.

• Clinical notes demonstrating criteria.

Low-cost tip:

• Use a two-paragraph appeal template with fill-in fields for EHB category, benchmark reference, and parity/anti-discrimination citations.

Case Study

A small pediatric therapy clinic treated a 7-year-old with developmental delays using habilitative occupational therapy and requested coverage for a specialized adaptive device. The plan denied coverage, citing an internal policy limiting devices to rehabilitative indications after injury. The clinic appealed, documenting that habilitative services and devices fall squarely within the EHB category for rehabilitative and habilitative services and devices, that coverage must be substantially equal to the benchmark (§ 156.115), and that categorical exclusions for developmental conditions can be discriminatory under § 156.125.

On reconsideration, the payer approved a limited quantity with a replacement schedule consistent with the state benchmark plan’s analogous device coverage. Financially, the clinic avoided a $1,250 write-off; reputationally, it strengthened family trust and reduced future prior auth cycle time by adding benchmark citations to its standard request template.

Wrap-up: This short list keeps your internal controls aligned to EHB’s most consequential provisions, reducing denials and supporting compliant appeals.

Common Pitfalls to Avoid Under 45 CFR 156 Subpart B

Before each point of failure, ask whether your workflow reflects the actual benchmark rules for your state and plan year.

• Assuming large-group/self-funded rules mirror EHB. Market misclassification causes bad expectations and avoidable disputes; EHB generally binds individual/small-group markets. Cite § 156.110 and § 156.115 only when they apply. Consequence: lost time and credibility in appeals.

• Ignoring benchmark supplementation. If a base benchmark historically lacked a category, plans must supplement coverage. Overlooking § 156.110(b) can forfeit coverage your patient is entitled to.

• Appealing without parity or anti-discrimination arguments. MH/SUD denials and categorical exclusions often implicate PHS Act § 2726 (via § 156.115) and § 156.125. Missed citations weaken appeals.

• Skipping preventive inclusion checks. Preventive services must be included under § 156.115(a)(4) and § 147.130. Patients may be improperly billed if staff miss this.

• Neglecting prescription drug adequacy. Formularies must meet § 156.122 standards. Failure to pursue exceptions with benchmark justification can leave patients without needed medications.

• Relying on outdated benchmark summaries. States may update benchmarks under § 156.111. Using old materials can lead to improper counseling and encounter planning.

Wrap-up: Avoid these traps by centering every denial review on the correct EHB category, the benchmark year, and the non-discrimination and parity guardrails.

Small clinics thrive on lean but precise processes.

• Create an “EHB One-Pager” for your state. Summarize the ten categories, any benchmark-specific quirks (e.g., therapy caps), and links to official summaries. This improves first-contact accuracy at check-in.

• Embed EHB fields in clinical templates. A simple field for “EHB category & benchmark criteria addressed” nudges providers to document what payers expect under § 156.115.

• Standardize appeal language. Pre-approved language that cites § 156.110(b), § 156.115, § 156.122, and § 156.125 equips staff to respond quickly.

• Quarterly denial huddles. Review one denial that raises EHB issues and update your templates accordingly.

• Cross-train front desk and billing. Ensure both teams know when preventive rules or parity requirements change the conversation.

Wrap-up: These practices turn complex federal rules into consistent, clinic-friendly habits.

Sustainable compliance is cultural. Assign a Compliance Point Person to own the EHB one-pager, monitor CMS/CCIIO updates under § 156.111, and liaise with payer reps. Train staff to flag potential § 156.125 discrimination issues and parity inconsistencies during routine work. Leaders should frame EHB as a patient-access equity initiative as much as a billing issue; this increases clinician engagement and improves documentation quality. Finally, incorporate EHB checks into onboarding so new staff understand why certain notes, codes, and attachments matter to coverage.

Summary: Essential Health Benefits define the floor of coverage for individual and small-group plans. While § 156.105 pertains to multi-state plans, clinics must operationalize the substantive EHB standards in §§ 156.110, 156.111, 156.115, 156.122, and 156.125, anchored by 42 U.S.C. § 18022. Teams that document to the benchmark, apply preventive service rules, ensure parity, and press formulary exceptions with the correct citations experience fewer denials and faster patient access.

Advisers (practical tools and resources):

• CMS/CCIIO EHB Benchmark Resources: Use the state benchmark listings and review guides to update your “EHB One-Pager” each year.

• eCFR/LII for 45 CFR 156 Subpart B: Quick lookups for exact text of §§ 156.110, 156.111, 156.115, 156.122, 156.125 to quote in appeals.

• CRS EHB Overviews: Readable primers that explain how benchmarks are selected and updated.

• State Department of Insurance Bulletins: Monitor state guidance that clarifies benchmark interpretation for issuers.

Also:

1. Build or update your State EHB One-Pager.

2. Add EHB category + benchmark criteria fields to templates.

3. Stand up a two-paragraph EHB appeal template referencing § 156.115, § 156.110(b), and § 156.125.

4. Schedule a monthly 15-minute denial huddle to reinforce learning and keep materials current.

• 42 U.S.C. § 18022 – Essential health benefits requirements (ACA § 1302)

• 45 CFR Part 156 Subpart B – Essential Health Benefits Package (table of sections and text)

• 45 CFR § 156.110 – EHB-benchmark plan standards

• 45 CFR § 156.115 – Provision of EHB

• 45 CFR § 156.122 – Prescription drug benefits

• 45 CFR § 156.125 – Prohibition on discrimination

• 45 CFR § 156.111 – State selection of EHB-benchmark plan (current rule and annual reporting)

• Information on Essential Health Benefits (EHB) Benchmark Plans – CMS/CCIIO

• Guide to Reviewing Essential Health Benefits Benchmark Plans – CMS/CCIIO

• The Patient Protection and Affordable Care Act’s Essential Health Benefits (CRS Report)