medicaid alternative benefit plans & essential health benefits barbara coulter edwards director...
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Medicaid Alternative Benefit Plans & Essential Health
BenefitsBarbara Coulter Edwards
DirectorDisabled and Elderly Health Programs Group
Center for Medicaid and CHIP ServicesCenters for Medicare & Medicaid Services
April 20, 2012
Deficit Reduction Act (DRA) of 2005 created new section 1937 of the Social Security Act
Increased flexibility for States to provide Medicaid coverage through tailored “benchmark” or “benchmark equivalent” benefit packages to specific populations
Mandatory enrollment limited to certain Medicaid beneficiary groups
Alternative Benefit Plans Today
Exempt from mandatory enrollment1. Blind or disabled2. Medically needy/frail3. Pregnant women4. Terminally ill individuals receiving hospice care5. Individuals entitled to benefits under Medicare6. Etc..
Alternative Benefit Plans Today
“Benchmark” coverage is a benefit plan that is either the same as: 1. Federal employees health benefit coverage;
2. State employees health benefit coverage; or
3. Coverage offered by the health maintenance organization (HMO) with the largest insured commercial non-Medicaid enrolled population in the State.
4. Secretary-approved coverage – Any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population proposed to be provided such coverage
Alternative Benefit Plans Today
“Benchmark-Equivalent” Coverage1. Benefit package has an aggregate actuarial value that is at
least equivalent to that of one of the Benchmark Benefit packages
2. Must include coverage for following services: Inpatient and outpatient hospital Physician’s surgical & medical Lab and x-ray Well baby/well child care (including immunizations) Emergency services Family planning services and supplies Mental health services Prescription drugs Other appropriate preventative services as designated by the
Secretary
Alternative Benefit Plans Today
States may provide “benchmark” or “benchmark-equivalent” coverage by obtaining employer sponsored health plans.
The State must assure that the employer sponsored plans meet the requirements of the benchmark/benchmark-equivalent coverage, including economy and efficiency.
A State may provide coverage through a combination of employer sponsored health plans and additional benefits coverage provided by the State.
Alternative Benefit Plans Today
States must assure enrollee access, through benchmark or benchmark-equivalent coverage or otherwise, to rural health clinic services and FQHC services.
Payments must be made in accordance with the Medicaid payment provisions for rural health clinics and FQHC services.
Alternative Benefit Plans Today
States must provide public notice and reasonable opportunity to comment before submitting benchmark/benchmark-equivalent plans and/or requesting changes to approved plans.
Alternative Benefit Plans Today
11 States, the District of Columbia, Guam and Puerto Rico have implemented Medicaid Alternative Benefit plans. Wisconsin implemented a plan equal to the commercial HMO
plan with the largest non-Medicaid enrollment in the States The following States and the District of Columbia implemented
Secretary approved benefit plans:
Connecticut (early option) Kentucky
District of Columbia (early option) Minnesota (early option)
Guam (early option) Missouri
New YorkPuerto Rico (early option)
Idaho Virginia
Kansas Washington
West Virginia
Alternative Benefit Plans Today
Effective March 23, 2010 Optional coverage of newly eligible prior to 2014
(may be phased in). Benefits must consist of benchmark or benchmark-equivalent coverage or full Medicaid State Plan
Benchmark and benchmark-equivalent benefit coverage for all enrollees must include family planning services and supplies and comply with mental health parity
Benchmark-equivalent coverage must include prescription drugs and mental health services
Alternative Benefit Plans Today
Alternative Benefit Plans 2014
Effective January 1, 2014 New expansion population of adults required to
receive benefits through a Section 1937 Alternative Benefit Plan MAGI eligible adults must receive benefits under
Section 1937 Alternative Benefit Plan Any benchmark/benchmark-equivalent plan must
provide at least the essential health benefits as defined by the Secretary
Impact All States will operate at least one Alternative
Benefit Plan Each State required to identify EHB plan Benchmark plans that can be referenced as EHB
benchmark plans State’s largest non-Medicaid HMO State’s employee health plan FEHPG Blue Cross/Blue Shield plan
State could also select full Medicaid benefit plan as coverage package
Alternative Benefit Plans 2014
Impact Allowing multiple Alternative Benefit Plans, EHB
reference plans Supplementation of benefits in benchmark may be
required to insure that all EHBs are offered in the State
No default EHB benchmark plan in Medicaid, States required to submit an Alternative Benefit
Plan State Plan Amendment to implement this change
Alternative Benefit Plans 2014
Future Considerations
Adding the ability for States to offer long-term services and supports in addition to 1905(a) services within the Alternative Benefit Plans
Allowing mandatory enrollment exemptions to apply to people in the VIII group
Implementing mental health parity within Alternative Benefit Plans
How to keep Alternative Benefit Plans/EHB “current”
SMD letter – 3/31/06 - Benchmark Benefit Plan Option (now referred to as Medicaid Alternative Benefit plan)
SHO letter – 4/9/10 - New Option for Coverage of Individuals
Final rule – 4/30/10 - http://www.gpo.gov/fdsys/pkg/FR-2010-04-30/pdf/2010-9734.pdf
SHO letter – 7/2/11 - Family Planning State Option & New Benefit Rules for Benchmark Benefit Plans
Issuances/Publications