Alternative Benefit Plan (ABP)

Template B5 – Alternative Benefit Plans Benefit Assurances

Statute: 1937(a)(1)(A)(ii), (a)(1)(e)(iii), (b)(4)

Regulation: 42 CFR 440.345, 440.365, 440.390

INTRODUCTION

In this template the State provides a number of assurances pertaining to its proposed Alternative Benefit Plan benefit package, such as those concerning providing access to EPSDT services, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) services, Essential Health Benefits, mental health and substance use disorder parity requirements, outpatient drugs, habilitation and rehabilitation services parity, and family planning services and supplies. The State is required to provide specific information concerning how it will comply with the EPSDT requirements.

BACKGROUND

Section 1937 of the Act and regulations in 42 CFR Subpart C have provisions requiring that the State provide EPSDT services to any individuals under age 21 participating in an Alternative Benefit Plan and also comply with requirements concerning access to and payment for RHC and FQHC services. Assurances are provided so that the State can assure it will comply with these requirements.

In addition, concerning the EPSDT requirements, the State must indicate on the template how it will provide the EPSDT services and how any additional benefits will be provided to meet this requirement.

The State must also provide an assurance that it will comply with the following benefit-related requirements:

• Covered Outpatient Drug requirements of Section 1927 of the Act by providing the Prescribed Drug coverage included in the State plan’s standard benefit package,

• Provision of Essential Health Benefits as required by Section 1302(b) of the Patient Protection and Affordable Care Act,

• Mental Health and Substance Use Disorder parity requirements of Section 1937(b)(6) of the Social Security Act,

• Provision of family planning services and supplies in accordance with Section 1937(b)(7) of the Act, and

• Habilitation services in parity with rehabilitation services as r4quired by 42 CFR 440.350(a)(2).

TECHNICAL GUIDANCE

The State must affirmatively indicate by selecting the first assurance that it will provide notice to individuals participating in Alternative Benefit Plan of how it will ensure access to EPSDT services for individuals less than 21 years of age.

The State must affirmatively elect the second assurance indicating that EPSDT services will be provided to individuals less than 21 years of age.

The State provides these affirmative assurances by checking the box next to the assurances. If the State does not check this box, the system will not accept this template for review and approval.

The State must then select from the two options presented to indicate how it will comply with the second assurance. This can be done either by providing EPSDT benefits:

• Through the Alternative Benefit Plan by covering all EPSDT services within the plan, or

• As additional benefits under Section 1937. If this option is chosen the State must indicate if it will provide the benefits through:

  • State contracts with a vendor to provide the EPSDT services and indicate the payment method that will be used to reimburse the vendor, or

  • Through fee-for-service payments directly the Medicaid agency.

States may then add additional information in the text box provided to describe how EPSDT services will be provided.

Review Criteria

The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the State’s election meets applicable federal statutory, regulatory and policy requirements.

Next the State must provide the following affirmative assurances:

Provide that Alternative Benefit Plan enrollees will have access to services in Rural Health Clinics and Federally Qualified Health Centers.

Provide that the Alternative Benefit Plan will use the prospective payment methodology for RHCs and FQHCs prescribed by section 1902(bb) in the same manner as with its standard State plan benefits.

Provide that it will comply with the requirements of Section 1927 of the Act concerning Covered Outpatient Drugs by providing as the Alternative Benefit Plan’s Prescription Drug coverage its standard State plan Prescribed Drugs benefit.

Provide that effective January 1, 2014 it will comply with Section 1937(b)(5) of the Act by providing at a minimum the essential health benefits described in section 1302(b) of the Affordable Care Act.

Provide that it will comply with Section 1937(b)(6) of the Act concerning mental health and substance use disorder parity requirements by ensuring that the financial requirements and treatment limitations applicable to such services meet the requirements of section 2705(a) of the Public Health Service Act.

Provide that it will comply with Section 1937(b)(7) of the Act provision of family planning services and supplies.

Provide that it will comply with regulations at 42 CFR 440.350(a)(2) by offering, at a minimum, habilitation services to acquire new skills in parity with rehabilitation services to restore skills.

The State provides these affirmative assurances by checking the box next to the assurances. If the State does not check this box, the system will not accept this template for review and approval.

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