CMS-10190 6044 Benchmark Preprint

1937(STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
Transmittal Number:

Medical Assistance Program
Supersedes:

Effective:

_____________________________________________________________
Section 3 – Services: General Provisions
3.1

Amount, Duration, and Scope of Services
Medicaid is provided in accordance with the requirements of sections 1902(a), 1902(e), 1902(z),
1903(i), 1905(a), 1905(p), 1905(r), 1905(s), 1906, 1915, 1916, 1920, 1925, 1929, and 1933 of the Act;
section 245(h) of the Immigration and Nationality Act; and 42 CFR Parts 431, 440, 441, 442, and 483
C. Benchmark Benefit Package and Benchmark Equivalent Benefit Package (provided in
accordance with 1937 of the Act and 42 CFR Part 440).
The State elects to provide alternative benefits:


Provided



Not Provided

{*Note to Contractor: States can have more than one alternative benefit plan. If the State has
more than one alternative benefit plan, as in the example below, then a pre-print would need to
appear for each additional Benchmark Plan title. Meaning, that if the box signifying “Plan A” was
checked then the remainder of the pre-print that would appear would be specific only to “Plan A”.
If “Plan B” was checked then the following pre-print that would appear would be a completely new
pre-print that would be filled out by the State and would correlate to “Plan B” only.}
 Title of Alternative Benefit Plan A
 Title of Alternative Benefit Plan B

1. Populations and geographic area covered
The State will provide the benefit package to the following populations:
a)  Populations who are full benefit eligibility individuals in a category established on or
before February 8, 2006, that may be required to enroll in an alternative benefit plan to
obtain medical assistance.
(Note: Populations listed in section 1b. may not be required to enroll in a benchmark plan,
even if they are part of an eligibility group included in 1a.)

For full benefit Medicaid eligibility groups included in the alternative benefit plan, please
indicate in the chart below:
• Each eligibility group the state will require to enroll in the alternative benefit
plan;
• Each eligibility group the state will allow to voluntarily enroll in the alternative
benefit plan;
• Specify any additional targeted criteria for each included group (e.g., income
standard);
• Specify the geographic area in which each group will be covered.

Required
Enrollment

Opt-In
Enrollment

Full-Benefit Eligibility Group and
Federal Citation
Mandatory categorically needy lowincome families and children eligible
under section 1925 for Transitional
Medical Assistance
Mandatory categorically needy poverty
level infants eligible under
1902(a)(10)(A)(i)(IV)
Mandatory categorically needy poverty
level children aged 1 up to age 6 eligible
under 1902(a)(10)(A)(i)(VI)
Mandatory categorically needy poverty
level children aged 6 up to age 19
eligible under 1902(a)(10)(A)(i)(VII)
Other mandatory categorically needy groups
eligible under 1902(a)(10)(A)(i) as listed
below and include the citation from the
Social Security Act for each eligibility
group:

•
•
•
•
Optional categorically needy poverty level
pregnant women eligible under
1902(a)(10)(A)(ii)(IX)
Optional categorically needy poverty level
infants eligible under 1902(a)(10)(A)(ii)(IX)
Optional categorically needy AFDC-related
families and children eligible under
1902(a)(10)(A)(ii)(I)
Medicaid expansion/optional targeted lowincome children eligible under
1902(a)(10)(A)(ii)(XIV)
Other optional categorically needy groups
eligible under 1902(a)(10)(A)(ii) as listed
below and include the citation from the
Social Security Act for each eligibility
group:

•

Targeting
Criteria

Geographic
Area

•
•
•
b)
The following populations will be given the option to voluntarily enroll in an alternative
benefit plan.
Please indicate in the chart below:
 Each eligibility group the state will allow to voluntarily enroll in the alternative
benefit plan,
 Specify any additional targeted criteria for each included group (e.g., income
standard).
 Specify the geographic area in which each group will be covered.

Opt-In
Enrollment

Included Eligibility Group and Federal Citation
Mandatory categorically needy low-income
parents eligible under 1931 of the Act
Mandatory categorically needy pregnant women
eligible under 1902(a)(10)(A)(i)(IV) or another
section under 1902(a)(10)(A)(i):
Individuals qualifying for Medicaid on the basis
of blindness
Individuals qualifying for Medicaid on the basis
of disability
Individuals who are terminally ill and receiving
Medicaid hospice benefits under
1902(a)(10)(A)(ii)(vii)
Institutionalized individuals assessed a patient
contribution towards the cost of care
Individuals dually eligible for Medicare and
Medicaid
Disabled children eligible under the TEFRA
option - section 1902(e)(3)
Medically frail and individuals with special
medical needs
Children receiving foster care or adoption
assistance under title IV-E of the Act
Women needing treatment for breast or cervical
cancer who are eligible under
1902(a)(10)(A)(ii)(XVIII)
Individuals eligible as medically needy under
section 1902(a)(10)(C)(i)(III)
Individuals who qualify based on medical
condition for long term care services under
1917(c)(1)(C)

Limited Services Individuals
TB-infected individuals who are eligible under
1902(a)(10)(A)(ii)(XII)
Illegal or otherwise ineligible aliens who are
only covered for emergency medical services

Targeting
Criteria

Geographic
Area

under section 1903(v)

c)

For optional populations/individuals (checked above in 1a. & 1b.), describe in the text box
below the manner in which the State will inform each individual that:
• Enrollment is voluntary;
• Each individual may choose at any time not to participate in an alternative
benefit package and;
• Each individual can regain at any time immediate enrollment in the
standard full Medicaid program under the State plan.

2. Description of the Benefits
 The State will provide the following alternative benefit package (check the one that applies).
a)  Benchmark Benefits
FEHBP-equivalent Health Insurance Coverage – The standard Blue
Cross/Blue Shield preferred provider option services benefit plan, described in
and offered under section 8903(l) of Title 5, United States Code.
 State Employee Coverage – A health benefits coverage plan that is offered
and generally available to State employees within the State involved.
In the text box below please provide either a World Wide Web URL (Uniform
Resource Locator) link to the State’s Employee Benefit Package or insert a
copy of the entire State’s Employee Benefit Package.

 Coverage Offered Through a Commercial Health Maintenance
Organization (HMO) – The health insurance plan that is offered by an HMO
(as defined in section 2791(b)(3) of the Public Health Service Act), and that has
the largest insured commercial, non-Medicaid enrollment of such plans within the
State involved.
In the text box below please provide either a World Wide Web URL link to
the HMO’s benefit package or insert a copy of the entire HMO’s benefit
package.

 Secretary-approved Coverage – Any other health benefits coverage that the

Secretary determines provides appropriate coverage for the population served.
Provide a full description of the benefits in the plan, including any applicable
limitations. Also include a benefit by benefit comparison to services in the
State plan or to services in any of the three Benchmark plans above.

b)  Benchmark-Equivalent Benefits.
Specify which benchmark plan or plans this benefit package is equivalent to:

(i)

Inclusion of Required Services – The State assures the alternative benefit plan
includes coverage of the following categories of services: (Check all that apply).
 Inpatient and outpatient hospital services;
 Physicians’
surgical and medical services;
 Laboratory and x-ray services;
 Well-baby and well-child care services as defined by the
State, including age-appropriate immunizations in accordance with the
Advisory Committee on Immunization Practices;
 Other appropriate preventive services including emergency services and
family planning services included under this section.

(ii)

 Additional services
Insert a full description of the benefits in the plan including any limitations.

(iii) 
•
•
•
•
•

The State assures that the benefit package has been determined to have an aggregate
actuarial value equivalent to the specified benchmark plan in an actuarial report that:
Has been prepared by an individual who is a member of the American Academy of
Actuaries;
Using generally accepted actuarial principles and methodologies;
Using a standardized set of utilization and price factors;
Using a standardized population that is representative of the population being served;
Applying the same principles and factors in comparing the value of different
coverage (or categories of services) without taking into account any differences in
coverage based on the method of delivery or means of cost control or utilization
used; and

•

Takes into account the ability of a State to reduce benefits by taking into account the
increase in actuarial value of benefits coverage without taking into account any
differences in coverage based on the method of delivery or means of cost control or
utilization used and taking into account the ability of the State to reduce benefits by
considering the increase in actuarial value of health benefits coverage offered under
the State plan that results from the limitations on cost sharing (with the exception of
premiums) under that coverage.
Insert a copy of the report.

iv  The State assures that if the benchmark plan used by the State for purposes of
comparison in establishing the aggregate value of the benchmark-equivalent package
includes any of the following four categories of services, the actuarial value of the
coverage for each of these categories of services in the benchmark-equivalent
coverage package is at least 75 % of the actuarial value of the coverage for that
category of service in the benchmark plan used for comparison by the State:
•
•
•
•

Prescription drugs;
Mental health services;
Vision services, and/or
Hearings services,

In the text box below provide a description of the categories of benefits
included and the actuarial value of the category as a percentage of the actuarial
value of the coverage for the category of services included in the benchmark
benefit plan.

c) 

Additional Benefits
 Insert a full description of the additional benefits including any limitations.
 Other Additional Benefits (If checked, please describe)

3. Service Delivery System
Check all that apply.
The alternative benefit plan will be provided on a fee-for-service basis
consistent with the requirements of section 1902(a) and implementing
regulations relating to payment and beneficiary free choice of provider.
The alternative benefit plan will be provided on a fee-for-service basis
consistent with the requirements cited above, except that it will be operated

with a primary care case management system consistent with section
1905(a)(25) and 1905(t).
The alternative benefit plan will be provided through a managed care
organization consistent with applicable managed care requirements (42 CFR
438, 1903(m), and 1932).
 The alternative benefit plan will be provided through PIHPs (Pre-paid
Inpatient Health Plan) consistent with 42 CFR 438.
The alternative benefit plan will be provided through PAHPs (Pre-paid
Ambulatory Health Plan).
The alternative benefit plan will be provided through a combination of the methods
described above. Please describe how this will be accomplished.

4. Employer Sponsored Insurance
The alternative benefit plan is provided in full or in part through premiums paid for an
employer sponsored health plan.

5. Assurances
 The State assures EPSDT services will be provided to individuals under 21 years old who are
covered under the State Plan under section 1902(a)(10)(A).
 Through Benchmark only
 As an Additional benefit under section 1937 of the Act
The State assures that individuals will have access to Rural Health Clinic (RHC) services
and Federally Qualified Health Center (FQHC) services as defined in subparagraphs
(B) and (C) of section 1905(a)(2).
The State assures that payment for RHC and FQHC services is made in accordance
with the requirements of section 1902(bb) of the Act.
The State assures transportation (emergency and non-emergency) for individuals enrolled in
an alternative benefit plan. Please describe how and under which authority(s) transportation is
assured for these beneficiaries

6. Economy and Efficiency of Plans

The State assures that alternative benefit coverage is provided in accordance with Federal
upper payment limits procurement
requirements and other economy and efficiency principles that would otherwise be applicable
to the services or delivery system through which the coverage and benefits are obtained.

7. Compliance with the Law
The State will continue to comply with all other provisions of the Social Security
Act in the administration of the State plan under this title.

8. Implementation Date
________________
The State will implement this State Plan amendment on l________________l (date).