---
kind: "section"
citation: "45 C.F.R. § 155.170"
title: "45"
number: "155.170"
heading: "Additional required benefits."
url: "https://uscodex.org/cfr/45/155.170"
---

# §155.170. Additional required benefits.

- (a) **Additional required benefits.**
  - (1) A State may require a QHP to offer benefits in addition to the essential health benefits. For plan years beginning before January 1, 2028, a benefit required by State action taking place on or before December 31, 2011, a benefit required by State action for purposes of compliance with Federal requirements, or a benefit covered in the State's EHB-benchmark plan is considered an EHB. A benefit required by State action taking place on or after January 1, 2012, other than for purposes of compliance with Federal requirements, that is not a benefit covered in the State's EHB-benchmark plan is considered in addition to the essential health benefits.
  - (2) For plan years beginning on or after January 1, 2028, a State may require a QHP to cover benefits in addition to the essential health benefits, which are any State-required benefits that are:
    - (i) Required by a State action taking place after December 31, 2011;
    - (ii) Applicable to the small group and/or individual markets;
    - (iii) Specific to required care, treatment, or services; and
    - (iv) **Not required by State action for purposes of compliance with Federal requirements.**
  - (3) A State must make payments in accordance with [paragraph (b)](#b) of this section to defray the cost of any State-required benefits in addition to the EHB.
  - (4) The State will identify which State-required benefits are in addition to the EHB.
- (b) **Payments.** The State must make payments to defray the cost of additional required benefits specified in [paragraph (a)](#a) of this section to one of the following:
  - (1) To an enrollee, as defined in [§ 155.20](/cfr/45/155.20.md) of this subchapter; or
  - (2) **Directly to the QHP issuer on behalf of the individual described in paragraph (b)(1) of this section.**
- (c) **Cost of additional required benefits.**
  - (1) Each QHP issuer in the State shall quantify cost attributable to each additional required benefit specified in [paragraph (a)](#a) of this section.
  - (2) A QHP issuer's calculation shall be:
    - (i) Based on an analysis performed in accordance with generally accepted actuarial principles and methodologies;
    - (ii) Conducted by a member of the American Academy of Actuaries; and
    - (iii) **Reported to the State.**

## Notes

### Amendments

[78 FR 12865, Feb. 25, 2013, as amended at 81 FR 12337, Mar. 8, 2016; 89 FR 26419, Apr. 15, 2024; 91 FR 29864, May 20, 2026]

### Authority

Authority: 42 U.S.C. 18021-18024, 18031-18033, 18041-18042, 18051, 18054, 18071, and 18081-18083.

### Source

Source: 77 FR 11718, Feb. 27, 2012, unless otherwise noted.

### Amendments

[78 FR 12865, Feb. 25, 2013, as amended at 81 FR 12337, Mar. 8, 2016; 89 FR 26419, Apr. 15, 2024; 91 FR 29864, May 20, 2026]