Alternative Benefit Plan (ABP)

Template B14 – Alternative Benefit Plans Base Benchmark Plan Administrative Table

Statute: 1937(b)(5), Affordable Care Act Section 1302(b)

Regulation: 45 CFR 156.100

INTRODUCTION

This is an administrative template that can be updated without requiring submission of a State Plan Amendment (SPA). It is used to record the benefits provided by the Base Benchmark Plan the State has selected in the B4-Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package and Cost Sharing template. This template also reflects the Section 1937 Benchmark Benefit Package, as well, if it is the same as the Base Benchmark Plan. In addition, this template is used to record supplemental Essential Health Benefits.

BACKGROUND

Section 1937(b)(5) of the Act requires that Alternative Benefit Plans include all of the ten Essential Health Benefits (EHBs) specified in Section 1302(b) of the Affordable Care Act. In addition, States must designate a Base Benchmark Plan from one of those specified in forthcoming regulations at 45 CFR 156.100, to define the provision of the Alternative Benefit Plan’s EHBs, in addition to any EHBs provided through the 1937 Coverage Option Benchmark Plan Benefit Package.

There is a possibility that the Benchmark Plan Benefit Package and Base Benchmark Plan selected for the Alternative Benefit Plan will not include benefits in all ten EHB categories. If one or more the EHBs are missing the State must choose one or more additional Base Benchmark Plans to fill the void in the EHB coverage. These are known as Supplemental benefits and these benefits must be recorded in this template as well.

It is not necessary or possible to make template entries in the Prescription Drugs or Pediatric Services Including Oral and Vision Care Essential Health Benefit categories. Because States are required to comply with the outpatient drug requirements of Section 1927 of the Act, they are required to provide their standard Medicaid State Plan prescribed drug benefit to participants in any Alternative Benefit Plan. This will therefore constitute the Prescription Drug benefit. Because EPSDT requirements apply to individuals under age 21 participating in Alternative Benefit Plans, Pediatric Services Including Oral and Vision Care are already required and to be provided based on the standard State Plan EPSDT benefit. It is therefore not necessary to record the commercial plan’s benefits for this EHB category.

TECHNICAL GUIDANCE

PREREQUISITE: The B4-Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package and Cost Sharing template must be completed before completing this template. On that template the State will choose its 1937 Coverage Option Benchmark Benefit Package and its Base Benchmark Plan. If both of these are the same only this template will be completed. If they are different, the State must also complete the administrative template that corresponds to the Benchmark Benefit Package that is chosen.

The template will display the name of the Base Benchmark Plan at the top based on the plan previously identified in the B4-Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package and Cost Sharing template.

Enter Benefits in Essential Health Benefit Categories

First the State must enter the names of the benefits from the Base Benchmark Plan by classifying them into one of the ten Essential Health Benefit categories. If the benefit does not fall into any of these categories the State may include it in the benefit package by entering it near the bottom of table in the Non-Essential Health Benefit section. The State must enter these Non-Essential Health Benefits if this Base Benchmark Plan is the same as the Benchmark Benefit Package plan. If not, it is optional for the State to include these benefits in the Alternative Benefit Plan benefit package.

Please confirm the above concerning Non-Essential Health Benefits. Since we are using the same administrative template to capture both the 1937 coverage option benefits and the Base Benchmark Plan benefits when they are the same, and since all 1937 coverage option benefits must be included, I assumed the state must include these benefits if the template is serving this dual purpose and only has the option to exclude them if it only includes the Base Benchmark Plan benefits.

It is not necessary or possible make entries in the Prescription Drugs or Pediatric Services Including Oral and Vision Care categories for the reasons explained above in the Background section.

Enter Supplemental Benefits

Review the benefits included in the Alternative Benefit Plan from the Base Benchmark Plan and the Benchmark Benefit Package and identify any Essential Health Benefits categories that do not include a benefit or are missing a benefit in any required subcomponent. For example if the Rehabilitative and Habilitative Services category includes only rehabilitative services the State will need to add a habilitative service.

Note: Can a state use a Benchmark Benefit Package benefit to cover a gap in Essential Health Benefits in the Base Benchmark Plan, or must all EHBs come from one the 156.100 health plans? If that is the case the state may be required to add a supplemental benefit from one of those plans even though the Alternative Benefit Plan already has the EHB covered from the Section 1937 Benchmark Benefit Package.

Add benefits from another Base Benchmark Plan to fill any missing EHB categories or subcategories. Identify the source Base Benchmark Plan.

Record Limitations, Authorization Requirements, and Provider Qualifications

• For each benefit in the Base Benchmark Plan, record any limitations on the amount, duration or scope of the benefits in the appropriate column.

• Indicate if there are any authorization requirements for the benefit and the type of authorization:

  • Prior Authorization

  • Concurrent Authorization

  • Post Authorization

  • Other

• Indicate which provider qualifications will be used for providers of the benefit:

  • Medicaid State Plan

  • Base Benchmark Plan

  • Both