Alternative Benefit Plan (ABP)

Template B7 – Alternative Benefit Plans Benchmark-Equivalent Assurances

Statute: 1937(b)(2) and (3)

Regulation: 42 CFR 440.335 and 440.340

INTRODUCTION

This template is used by the State to record its assurances regarding complying with the statutory and regulatory requirements for Benchmark-Equivalent Plans. It also captures information concerning whether the comparison Benchmark Plan used to calculate equivalency includes vision or hearing services and, if so, presents additional assurances concerning required coverage of these services in the Benchmark-Equivalent Benefit Package.

BACKGROUND

This template includes a number of assurances regarding the process for establishing the actuarial value of the Benchmark-Equivalent benefit package and the Benchmark Plan to which it is at least actuarially equivalent. Section 1937(b)(2)(B) requires that any proposed Benchmark-Equivalent package be at least actuarially equivalent to a comparison Benchmark Plan. Section 1937(b)(3) and 42 CFR 440.340 contain detailed requirements concerning the preparation the actuarial reports. States must comply with all of these requirements for any actuarial reports submitted.

The template also includes assurances that the Benchmark-Equivalent benefits meet the 75% actuarial value test for vision or hearing benefits included in the Section 1937 Benchmark benefit package that is the basis for actuarial equivalency, if this Benchmark benefit package includes vision or hearing benefits.

There is a final assurance that the State has included in the actuarial report a description of the vision and/or hearing benefits included in the Benchmark Plan and their actuarial value as a percentage of the actuarial value of the benefits included in the Benchmark-Equivalent plan.

TECHNICAL GUIDANCE

Affirmatively respond by checking each of the assurances included in the template that specify the requirements that the State must adhere to in preparing its actuarial report to support a finding of actuarial equivalency for Benchmark-Equivalent benefit package and the Section 1937 Benchmark benefit package that the actuarial equivalency is based on.

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.

Next, respond to the assurance providing that the State will include the mandatory services prescribed by Section 1937(b)(2)(A) in its Benchmark-Equivalent benefit package.

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

Next, respond to the statements concerning coverage of vision and hearing services by the Section 1937 Benchmark benefit package used to calculate actuarial equivalency.

• Indicate yes or no, if the Benchmark-Equivalent Benefit package include vision services.

• If yes, affirmatively respond to the assurance that the value of the coverage for vision services in the Benchmark-Equivalent package is at least 75% of the value of the same coverage provided in the comparison Section 1937 Benchmark benefit package.

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

• Indicate yes or no, if the Benchmark-Equivalent Benefit package include hearing services.

• If yes, affirmatively respond to the assurance that the value of the coverage for hearing services in the Benchmark-Equivalent package is at least 75% of the value of the same coverage provided in the comparison Section 1937 Benchmark benefit package.

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

Affirmatively respond to the final assurance that the State has included in the actuarial report a description of the vision and/or hearing benefits included in the Section 1937 Benchmark benefit package and their actuarial value as a percentage of the actuarial value of the benefits included in the Benchmark-Equivalent plan.

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

Finally, the State may provide in the text box provided any additional information it considers important for the CMS reviewer to consider when reviewing this template.

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