1204POPULATIONEDWARDS (Slide 1)
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Transcript 1204POPULATIONEDWARDS (Slide 1)
Medicaid Alternative Benefit Plans
& Essential Health Benefits
Barbara Coulter Edwards
Director
Disabled and Elderly Health Programs Group
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services
April 20, 2012
Alternative Benefit Plans Today
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 enrollment
1.
2.
3.
4.
5.
6.
Blind or disabled
Medically needy/frail
Pregnant women
Terminally ill individuals receiving hospice care
Individuals entitled to benefits under Medicare
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” Coverage
1. 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 “benchmarkequivalent” 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 York
Puerto 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 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
Alternative Benefit Plans 2014
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
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”
Issuances/Publications
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/FR2010-04-30/pdf/2010-9734.pdf
SHO letter – 7/2/11 - Family Planning State Option &
New Benefit Rules for Benchmark Benefit Plans