A. As used in this section:
“Bureau” means the Bureau of Insurance of the State Corporation Commission.
“Essential health benefits benchmark plan” or “benchmark plan” has the same meaning as “EHB-benchmark plan” provided in 45 C.F.R. § 156.20.
B. The Commission, in coordination with the Bureau, shall conduct a review of the essential health benefits benchmark plan in 2025 and every five years thereafter in accordance with 45 C.F.R. § 156.111 and this section.
C. Prior to any review year, the Bureau shall convene a work group of relevant stakeholders to discuss and make recommendations regarding any potential changes to the benchmark plan. Members of the work group shall possess demonstrated and acknowledged expertise in health benefit plan design, actuarial science, population health, patient advocacy, or advocating for or assisting enrollees in individual or small group health coverage. Factors the work group shall consider include (i) coverage denial rates of benefits that are not covered under the current benchmark plan; (ii) the utilization of mandated benefits; (iii) the projected impact of a proposed mandate on the prevalence of medical need, the urgency of such medical need, and any disproportionate disease burden borne by different subpopulations; (iv) the projected cost of each proposed mandate; and (v) other data as determined by the work group. Additionally, for any referred legislation the Commission has chosen to be considered in the benchmark plan review, the Bureau shall complete an assessment of such legislation that includes an estimate of the effects of including the proposed mandate as part of the benchmark plan on the costs of health coverage in the Commonwealth. The Bureau shall submit the findings and any recommendations of the work group and any assessments of proposed mandates to the Commission by March 31 of the review year.
D. By June 30 of any review year, the Commission shall determine if an application will be made for a change to the benchmark plan and shall identify any potential benefit changes to the benchmark plan for further analysis. In making its determination and identifying any potential benefit changes, the Commission may consider (i) the findings and recommendations of the work group, (ii) any referred legislation the Commission has chosen to be considered in the benchmark plan review and the Bureau’s assessment of such legislation, and (iii) public comment. If the Commission determines that an application will be made for a change to the benchmark plan, the Commission shall identify any potential benefit changes for further analysis.
E. The Bureau shall conduct an actuarial analysis of any benefit changes identified by the Commission and present such analysis to the Commission by September 30 of such review year.
F. By December 31 of any review year, the Commission shall determine which, if any, potential benefit changes shall be included in a new benchmark plan. The Commission shall make a recommendation to the General Assembly in the form of a bill that directs the Bureau to select a new benchmark plan that includes any such changes at the next regular session of the General Assembly.
G. During the review year, the Commission shall conduct public hearings to solicit feedback from consumers and other interested parties regarding any potential benefit changes to the benchmark plan. At least two public hearings shall be held prior to the Commission’s determination required by subsection D. If the Commission has determined that an application for a new benchmark plan will be made for a change to the benchmark plan, at least two additional public hearings shall be held prior to selection of a new benchmark plan required by subsection F. Such hearings shall be adequately advertised and planned and shall include an opportunity for the public to participate both in-person and remotely.
H. The Bureau shall establish and maintain a website to convey relevant information to the public related to any benchmark plan review.