Alternative Benefit Plan (ABP)

Template B11 – Alternative Benefit Plans – FEHBP Benchmark Benefit Package

Template B12 – Alternative Benefit Plans – State Employee Coverage

Template B13 – Alternative Benefit Plans – Commercial HMO Coverage

Statute: 1937(b)(1)

Regulation: 42 CFR 440.330

INTRODUCTION

States may elect to provide Alternative Benefit Plan benefits based on Section 1937 Benchmark coverage. These templates are used to record the benefits provided using three of the four Benchmark Plan options that use commercial health plans as their basis. These administrative templates are completed if the Section 1937 Benchmark Plan benefit package is different from the Base Benchmark Plan used to define Essential Health Benefits. If they are the same this data is captured in the B14-Base Benchmark Plan Administrative template.

BACKGROUND

Section 1937 of the Act and 42 CFR 440.330 provide that States may elect to provide their Alternative Benefit Plan Benchmark Plan benefit package based on one of three commercial Benchmark options (Federal Employee Health Benefit Plan (FEHBP), State Employee Coverage, or the State’s largest Commercial HMO coverage) or Secretary-Approved Coverage, which is usually based primarily on the State’s Medicaid State plan.

Because the content of the three commercial Section 1937 Benchmark plans are not subject to State discretion, the initial update and subsequent annual changes to the benefits provided by these plans will not require submission of a State Plan Amendment. Instead the content of these administrative templates can be directly updated without submitting a State Plan Amendment (SPA) from the ?? (need location from Northrup Grumman) by selecting Administrative Data Update.

States may also update these tables within the Alternative Benefit Plan section of MACPro if they are concurrently submitting a State Plan Amendment related to other sections of the Alternative Benefit Plan. This benefit data is then used in the table of benefits for the B4a FEHBP Benchmark Plan, the B4b State Employee Coverage Benchmark Plan, or the B4c Commercial HMO Benchmark Plan, if the State has selected one of these Benchmark Plans as the basis for the section 1937 coverage option on the B4 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package and Cost Sharing template.

States use these templates to record these commercial benefits if the Section 1937 coverage option is different from the Base Benchmark Plan. If the two plans are the same the benefits associated with the benefit plan are recorded in the B14-Base Benchmark Plan template.

In addition to listing the benefit package’s benefits the State also indicates any limitations on amount, duration or scope defined by the commercial plan. States will also place each benefit into one of the ten Essential Health Benefit categories in this table if it is an Essential Health Benefit.

If there are benefit package benefits that are not EHBs, there is a section to record non-Essential Health benefits provided in the benefit package. The State is not required to use these non-EHB benefits from the Base Benchmark Plan, but it is required to use all of the benefits in the section 1937 coverage option, including non-EHBs.

States will initially record benefits based on those in effect during the first quarter of 2012. These will remain in effect for the period January 1, 2014 through December 31, 2015, and will be evaluated for application in future years. CMS will consult with states and reevaluate the process to determine how often states would need to update these types of Alternative Benefit Plans to reflect changes made to Section 1937 commercial plans and EHBs in individual and small group plans.

TECHNICAL GUIDANCE

PREREQUISITE: The B4-Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package and Cost Sharing template must be completed first. Based on the Benchmark Benefit Package selected on that template these administrative templates may be presented as long as the Base Benchmark Plan selected in that template is different. If it is the same, the benefits for the Benchmark Benefit Package are described in the B14-Base Benchmark Plan template and this template does not need to be completed.

The name of the specific commercial plan will be displayed at the top of the table. For FEHBP this is prescribed by law to be The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit program (FEHBP). For State Employee and Commercial HMO coverage it is the plan the State indicates in the B4 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package and Cost Sharing template.

• The State should enter into the table the name of each benefit in the commercial plan in the section that corresponds to the appropriate ACA Essential Health Benefit.

• For each benefit that is entered, if there are any limitations on the amount, duration or scope of benefits prescribed by the commercial plan, describe these in the appropriate column in the table. If there are no limitations, leave these columns blank.

• If the State will require authorization for any benefits, indicate this in the Authorization Required column along with the specific type of authorization that will be used.

• For each benefit indicate the basis of the Provider Qualifications for providers of the benefit. The State may select to use the commercial plan’s provider qualifications or the Medicaid State plan provider qualifications, or it can select both.

• If any of the plan’s benefits do not fall into one of the Essential Health Benefit categories record these in the Non-ACA Essential Health Benefits section of the table and then complete the limitations, authorization and provider qualification columns for each benefit.