By Zoe Bulls
On January 28, 2025, the Department of Managed Health Care (DMHC) held a second stakeholder meeting and presented an actuarial analysis outlining the benefit allowance, potential coverage options, and cost projections for the proposed California’s Essential Health Benefits (EHB) benchmark plan. The Affordable Care Act requires health plans to cover services across ten broad categories of health care, including primary care, hospital services, prescription drugs, and emergency services. Each state adopts an EHB benchmark plan to define the specific services that health plans must cover within these categories.
Members of the public, advocacy groups, and health plans again provided feedback on the services that should or should not be included in the benchmark plan. On February 11, 2025, the California Legislature held a joint informational hearing to gather additional stakeholder input on adopting a new EHB benchmark plan.
DMHC launched the EHB benchmark plan update process with a public hearing on June 27, 2024. At that meeting, DMHC outlined the update timeline and introduced a consultant who explained federal rules and recent EHB benchmark changes in other states. DMHC accepted oral public comments and requested written public comments by July 11, 2024. Health advocacy interest groups and individuals requested the inclusion of, among other services, hearing aids for children, infertility treatment, and durable medical equipment such as wheelchairs, oxygen equipment, and CPAP machines. Health plans and insurers emphasized the need to balance benefits, costs, and access.
Based on this process, DMHC and the Legislature identified several benefits that align with the actuarial limitations and could be added to California’s EHB benchmark plan. These benefits include hearing aids for children and adults, expanded durable medical equipment (such as power wheelchairs, scooters, augmented communication devices, portable oxygen, and CPAP machines), and infertility services (including egg and sperm retrieval and storage, embryo creation and storage, in vitro fertilization, and medical costs related to surrogacy).
Since 2023, legislative efforts to expand health plan coverage requirements in California have underscored the need for an updated EHB benchmark plan. On October 7, 2023, Governor Newsom vetoed SB 635 (Menjivar, 2023), which would have required health plans to cover medically necessary hearing aids for enrollees under 21. He cited concerns that the bill would expand coverage requirements beyond California’s EHB benchmark plan and force the state to pay for additional services for individuals purchasing coverage through Covered California. On September 9, 2024, Governor Newsom signed SB 729 (Menjivar) (Chapter 930, Statutes of 2024), which mandates coverage for infertility diagnosis and treatment, including fertility services. However, he delayed the bill’s effective date until January 1, 2026, to allow the EHB benchmark update process to address the same coverage changes required by the bill.
On March 4, 2025, DMHC provided public notice on its intent to release a draft proposal for the new EHB benchmark plan in mid-March. Following the release, DMHC held a three-week written comment period to gather additional stakeholder feedback. Health care consumers who are interested in reviewing the draft proposal and submitting comments can sign up for DMHC’s mailing list or check the DMHC website for updates.