Essential Health Benefits

View of Vermont tree tops and mountains

Vermont’s Benchmark Plan

As of 2014, the federal health care law now requires all health plans to cover a basic set of health care services. The basic services offered in health plans are now the same in every state, but in Vermont we also have the existing state mandated services.

In August 2012, the Department of Vermont Health Access recommended a benchmark plan to the Green Mountain Care Board for their review and approval. The Green Mountain Care Board approved that plan in October 2012. Vermont chose the largest small-employer plan, offered by Blue Cross Blue Shield of Vermont, with the state CHIP plan for pediatric oral care and the FEDVIP plan for pediatric vision. This decision was made after consulting with stakeholders and comparing all plans. The selection of the Blue Cross Blue Shield plan meant the least amount of change for the largest number of Vermonters. With this selection, 77 percent of the people who are expected to use Vermont Health Connect continue to receive the same benefits they received in 2012, in addition to added benefits outlined by the federal health care law.

The health care services that all health plans are now required to cover are called “Essential Health Benefits.” These benefits include:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

As for prescription drugs,  Vermont qualified health plans are required by federal regulations to offer the greater of one drug in each category or class or the same number of drugs as the BCBSVT benchmark plan.  Read a detailed description of Vermont’s benchmark plan, which includes the submission count of prescription drugs for each class and category.  Since there are more than one drug for some class levels, Vermont adopted the BCBSVT plan for prescription drugs.  You can also view the to federal regulation for prescription drug classification:  45 CFR §156.122.