---
kind: "section"
citation: "45 C.F.R. § 156.115"
title: "45"
number: "156.115"
heading: "Provision of EHB."
url: "https://uscodex.org/cfr/45/156.115"
---

# §156.115. Provision of EHB.

- (a) Provision of EHB means that a health plan provides benefits that—
  - (1) **Are substantially equal to the EHB-benchmark plan including—**
    - (i) Covered benefits;
    - (ii) Limitations on coverage including coverage of benefit amount, duration, and scope; and
    - (iii) Prescription drug benefits that meet the requirements of [§ 156.122](/cfr/45/156.122.md) of this subpart;
  - (2) **Are required by a State action taking place on or before December 31, 2011.**
  - (3) With the exception of the EHB category of coverage for pediatric services, do not exclude an enrollee from coverage in an EHB category.
  - (4) With respect to the mental health and substance use disorder services, including behavioral health treatment services, required under [§ 156.110(a)(5)](/cfr/45/156.110.md?p=a-5), comply with the requirements under section 2726 of the Public Health Service Act and its implementing regulations.
  - (5) Include preventive health services described in [§ 147.130](/cfr/45/147.130.md) of this subchapter.
  - (6) **With respect to habilitative services and devices—**
    - (i) Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings;
    - (ii) Do not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices; and
    - (iii) For plan years beginning on or after January 1, 2017, do not impose combined limits on habilitative and rehabilitative services and devices.
  - (7) For plan years beginning on or after January 1, 2016, for pediatric services that are required under [§ 156.110(a)(10)](/cfr/45/156.110.md?p=a-10), provide coverage for enrollees until at least the end of the month in which the enrollee turns 19 years of age.
- (b) An issuer of a plan offering EHB may substitute benefits for those provided in the EHB-benchmark plan under the following conditions—
  - (1) **The issuer substitutes a benefit that—**
    - (i) Is actuarially equivalent to the benefit that is being replaced as determined in [paragraph (b)(4)](#b-4) of this section; and
    - (ii) **Is not a prescription drug benefit.**
  - (2) An issuer may substitute a benefit within the same EHB category, unless prohibited by applicable State requirements. Substitution of benefits between EHB categories is not permitted.
  - (3) **The plan that includes substituted benefits must—**
    - (i) Continue to comply with the requirements of [paragraph (a)](#a) of this section, including by providing benefits that are substantially equal to the EHB-benchmark plan;
    - (ii) Provide an appropriate balance among the EHB categories such that benefits are not unduly weighted toward any category; and
    - (iii) **Provide benefits for diverse segments of the population.**
  - (4) **The issuer submits to the State evidence of actuarial equivalence that is—**
    - (i) Certified by a member of the American Academy of Actuaries;
    - (ii) Based on an analysis performed in accordance with generally accepted actuarial principles and methodologies;
    - (iii) Based on a standardized plan population; and
    - (iv) **Determined without taking cost-sharing into account.**
- (c) A health plan does not fail to provide EHB solely because it does not offer the services described in [§ 156.280(d)](/cfr/45/156.280.md?p=d) of this subchapter.
- (d) For plan years beginning before January 1, 2026, an issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, or non-medically necessary orthodontia as EHB. For plan years beginning on any day in calendar year 2026, an issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, non-medically necessary orthodontia, or specified sex-trait modification procedures (as defined at [§ 156.400](/cfr/45/156.400.md)) as EHB. For plan years beginning on or after January 1, 2027, an issuer of a plan offering EHB may not include routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, non-medically necessary orthodontia, or specified sex-trait modification procedures (as defined at [§ 156.400](/cfr/45/156.400.md)) as EHB.

## Notes

### Amendments

[78 FR 12866, Feb. 25, 2013, as amended at 80 FR 10871, Feb. 27, 2015; 81 FR 12349, Mar. 8, 2016; 83 FR 17069, Apr. 17, 2018; 86 FR 53506, Sept. 27, 2021; 87 FR 27390, May 6, 2022; 89 FR 26425, Apr. 15, 2024; 90 FR 27223, June 25, 2025; 91 FR 29874, May 20, 2026]

### Source

Source: 78 FR 12866, Feb. 25, 2013, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 18021-18024, 18031-18032, 18041-18042, 18044, 18054, 18061, 18063, 18071, 18082, and 26 U.S.C. 36B.

### Source

Source: 76 FR 77411, Dec. 13, 2011, unless otherwise noted.

### Amendments

[78 FR 12866, Feb. 25, 2013, as amended at 80 FR 10871, Feb. 27, 2015; 81 FR 12349, Mar. 8, 2016; 83 FR 17069, Apr. 17, 2018; 86 FR 53506, Sept. 27, 2021; 87 FR 27390, May 6, 2022; 89 FR 26425, Apr. 15, 2024; 90 FR 27223, June 25, 2025; 91 FR 29874, May 20, 2026]