CMS-10510 Blueprint

^{Basic Health Program Blueprint}

Introduction

Section 1331(a) of the Affordable Care Act directs the Secretary to establish a Basic Health Program (BHP) that provides a new option for states to offer health coverage for individuals with family incomes between 133 and 200 percent of the federal poverty level (FPL) and for individuals from 0-200 percent FPL who are lawfully present in the United States but do not qualify for Medicaid due to their immigration status. This coverage is in lieu of Marketplace coverage.

States choosing to operate a BHP must submit this BHP Blueprint as an official request for certification of the program.

States operating a BHP enter into contracts to provide standard health plan coverage to eligible individuals. Eligible individuals in such a state could enroll in BHP coverage and would not have access to coverage through the Health Insurance Marketplace. The amount of the monthly premium and cost sharing charged to eligible individuals enrolled in a BHP may not exceed the amount of the monthly premium and cost sharing that an eligible individual would have paid if he or she were to receive coverage from a qualified health plan (QHP) through the Marketplace. A state that operates a BHP will receive federal funding equal to 95 percent of the premium tax credit (PTC) and the cost-sharing reductions (CSR) that would have been provided to (or on behalf of) eligible individuals, using a methodology set forth in a separate funding protocol based on a methodology set forth in companion rulemaking.

Given the population served under BHP, the program will sit between Medicaid and the Marketplace, and while states will have significant flexibility in how to establish a BHP, the program must fit within this broader construct and be coordinated with other insurance affordability programs. Regulations for the BHP were finalized on March 12, 2014 and are available at https://www.medicaid.gov/basic-health-program/index.html.

The BHP Blueprint is intended to collect the design choices of the state and ensure that we have a full understanding of the operations and management of the program and its compliance with the federal rules; it is not intended to duplicate information that we have collected through state applications for other insurance affordability programs. In the event that a State seeks to make a significant change(s) that alter program operations described in the certified Blueprint, the state must submit a revised Blueprint to the Secretary for review and certification.

The BHP Blueprint sections reflect the final rule that codified program establishment standards, eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, and Secretarial oversight relating to BHP.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1218. The time required to complete this information collection is estimated to range (on average) from 44 to 100 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Acronyms List

BHP Basic Health Program

CHIP Children’s Health Insurance Program

CSR Cost Sharing Reduction

ESI Employer Sponsored Insurance

EHB Essential Health Benefits

FPL Federal Poverty Level

IAP Insurance Affordability Program

MEC Minimum Essential Coverage

OMB Office of Management and Budget

PTC Premium Tax Credit

QHP Qualified Health Plan

SHP Standard Health Plan

Section 1: Basic Health Program-State Background Information

State Name:

Program Name (if different than Basic Health Program): Click or tap here to enter text.

BHP Blueprint Designated State Contact:

Name: Enter name

Title: Enter title

Phone: Enter phone number

Email: Enter email

Requested Initial Interim Certification Date (if applicable): Pick date.

Requested Initial Full Certification Date: Click or tap to enter a date.

Requested Initial Program Effective Date: Click or tap to enter a date.

Blueprint Revisions:

Revision number	Summary	Effective date	Certification date
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Administrative agency responsible for BHP (“BHP Administering Agency”):

Click or tap here to enter text.

BHP State Administrative Officers:

Position	Title	Location (Agency)	Responsible for:
Enter text.	Enter text.	Enter text.	Enter text.
Enter text.	Enter text.	Enter text.	Enter text.
Enter text.	Enter text.	Enter text.	Enter text.
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Program Administration: (Management, Policy, Oversight)

Position	Title	Location (Agency)	Responsible for:
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Program Administration: (Contracting, Eligibility Appeals, Coverage Appeals)

Position	Title	Location (Agency)	Responsible for:
Enter text.	Enter text.	Enter text.	Enter text.
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Finance: (Budget, Payments)

Position	Title	Location (Agency)	Responsible for:
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Governor or Designee: Governor or Designee.

Signature: Enter full name.

^{Date of} Official Submission: Date of official submission

Section 2: Public Input

This section of the Blueprint records the state’s method for meeting the public comment process required for Blueprint submission. This section applies only to the current Blueprint submission.

Date public comment period opened: Select date

Date public comment period closed: Select date

Please describe the public comment process used in your state, such as public meetings, legislative sessions/hearing, the use of electronic listservs, etc.:

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Provide a list below of the groups/individuals that provided public comment:

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If the state has federally recognized tribes, list them below. Provide an assurance that they were included in public comment and note if comments were received.

Federally recognized tribe	State agency solicited input (Indicate with an “X” if input was solicited)	Input received (Indicate with an “X” if input was solicited)
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Provide a brief summary of public comments received and the changes made, if any, in response to public comments:

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Section 3: Trust Fund

Please provide the BHP Trust Fund location and relevant account information.

Institution:

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Address:

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Phone Number:

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Account Name:

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Account Number:

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Trustees

Name	Organization	Title	May authorize withdrawals? (Indicate with an “X” if named individual can authorize withdrawals)
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	☐
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Is anyone other than Trustees indicated above able to authorize withdrawals?

If yes, please include the name and title of everyone with this authority.

Name	Organization	Title
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If there is separation between the entity holding the trust fund (“Trustees”) and the entity operating the trust fund, please describe the relationship below. Include the name, and contacts for the entity operating the trust fund. Also include a copy of a written agreement outlining the responsibilities of the entity operating the trust fund.

Name	Organization	Title	Contact
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Please name the CMS primary contact for the BHP trust fund and provide contact information.

CMS Primary Contact Name: Click or tap here to enter text.

CMS Primary Contact Phone: Click or tap here to enter text.

CMS Primary Contact Email: Click or tap here to enter text.

Please describe the process of appointing trustees:

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Provide a list of all responsibilities of Trustees:

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Has the state made any arrangements to insure or indemnify trustees against claims for breaches of fiduciary responsibility?

If yes, what are they?

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Trust Fund Attestation	Attest that the Agency is immediately ready and able. (Indicate with an “X” to signal attestation.)	Date the Agency commits to being ready to perform task if not immediately able. (mm/dd/yyyy)
The BHP Administering Agency will:
600.710(a) Maintain an accounting system and fiscal records in compliance with Federal requirements for state grantees, including OMB circulars A-87 and A-133 and applicable federal regulations.	☐	Click or tap to enter a date.
600.710(b) Obtain an annual certification from the BHP Trustees, the State’s CFO, or designee, certifying the state’s BHP Trust Fund FY financial statements, and certifying that BHP trust funds are not being used for the non-federal share for any Federally funded program, and that the use of BHP trust funds is otherwise in accordance with Federal requirements (including that use of BHP funds is limited to permissible purposes).	☐	Click or tap to enter a date.
600.710(c) Conduct an independent audit of Trust Fund expenditures over a 3-year period in accordance with chapter 3 of GAO’s Government Auditing Standards.	☐	Click or tap to enter a date.
600.710(d) Publish annual reports on the use of funds within 10 days of approval by the trustees.	☐	Click or tap to enter a date.
600.710(e) Establish and maintain BHP Trust Fund restitution procedures.	☐	Click or tap to enter a date.
600.710(f) and (g) Retain records for 3 years from the date of submission of a final expenditure report or until the resolution and final actions are completed on any claims, audit or litigation involving the records.	☐	Click or tap to enter a date.

Section 4: Eligibility & Enrollment

This section of the Blueprint records the state’s choices in determining eligibility procedures for BHP and records assurances that demonstrate comportment with BHP standards. The state must check all pertinent boxes and fill in dates where applicable.

Please name the agency with primary responsibility for the function of performing eligibility determinations:

Attestation	Completed (Indicate with an “X” to signal completion)	If No, Expected Completion Date (mm/dd/yyyy)	Marketplace Policy (Indicate with an “X” if Marketplace Policy applies)	Medicaid Policy (Indicate with an “X” if Medicaid Policy applies)
Eligibility Standards
The state can enroll an individual in a Standard Health Plan who meets ALL of the following standards.	☐	Click or tap to enter a date.	N/A	N/A
305(a)(1) Resident of the State.	N/A	N/A	N/A	N/A
305(a)(2) Citizen with household income exceeding 133 but not exceeding 200% FPL or lawfully present non-citizen ineligible for Medicaid or CHIP due to immigration status with household income below 200% FPL.	N/A	N/A	N/A	N/A
305(a)(3) Not eligible to enroll in MEC or affordable ESI.	N/A	N/A	N/A	N/A
305(a)(4) Less than 65 years old.	N/A	N/A	N/A	N/A
305(a)(6) Not incarcerated other than during disposition of charges.	N/A	N/A	N/A	N/A
Application Activities
310(a) Single streamlined application includes relevant BHP information.	☐	Click or tap to enter a date.	N/A	N/A
310(b) Application assistance, including being accessible to persons who are limited English proficient and persons who have disabilities consistent with 42 CFR435.905(b), is equal to Medicaid.	☐	Click or tap to enter a date.	N/A	N/A
310(c) State is permitting authorized representatives; indicate which standards will be used.	☐	Click or tap to enter a date.	☐	☐
315 State is using certified application counselors; indicate which standards will be used.	☐	Click or tap to enter a date.	☐	☐
Eligibility Determinations and Enrollment
320(c) Indicate the standard used to determine the effective date for eligibility.	☐	Click or tap to enter a date.	☐	☐
320(d) Indicate the enrollment policy used in BHP (the open and special enrollment periods of the Exchange OR the continuous enrollment process of Medicaid).	☐	Click or tap to enter a date.	☐	☐
335(b) Indicate the standard used for applicants to appeal an eligibility determination.	☐	Click or tap to enter a date.	☐	☐
340(c) Indicate the standard used to redetermine BHP eligibility.	☐	Click or tap to enter a date.	☐	☐
345 Indicate the standard to verify the eligibility of applicants for BHP.	☐	Click or tap to enter a date.	☐	☐

Note: N/A = Not applicable; indicates that there are no choices available.

1. Please indicate whether the state will implement continuous eligibility and redetermine enrollees every 12 months as long as enrollees are under 65, not enrolled in alternative MEC and remain state residents.

If no, please explain redetermination standards. (These standards must be in compliance with 42 CFR 600.340(f).)

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2. Please list the standards established by the state to ensure timely eligibility determinations. (These standards must be in compliance with 42 CFR 435.912 exclusive of 435.912(c)(3)(i)).

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3. Please describe the state’s process and timeline for incorporating BHP into the eligibility service in the state including the State’s Marketplace (if applicable). Include pertinent time-frames and any contingencies that will be used until system changes (if necessary) can be made.

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4. Please describe the process the state is using to coordinate BHP eligibility and enrollment with other IAPs in such a manner as to ensure seamlessness to applicants and enrollees.

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5. If the state is submitting a transition plan in accordance with 600.305(b), please describe the transition plan in the box below. The plan must include dates by which the state intends to complete transition processes and convert to full implementation.

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Section 5: Standard Health Plan Contracting

This portion of the Blueprint collects information about the service delivery system that will be used in the state as well as how the state plans to contract within that system.

Delivery Systems

1. Please assure that standard health plans from at least two offerors are available to enrollees. ☐

2. If applicable, please describe any additional activities the state will use to further ensure choice of standard health plans to BHP enrollees.

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3. If the state is not able to assure choice of at least two standard health plan offerors as described in question 1, please attach the state’s exception request. This exception request must include a justification as to why it cannot assure choice of standard health plan offeror and demonstrate that it has reviewed its competitive contracting process in accordance with 42 CFR 600.420(a)(i) - (iii).

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4. Is the state participating in a regional compact?

IF YES, please answer questions 5 - 9. If no, please skip questions 5 - 9.

5. Please indicate the other states participating in the regional compact.

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6. Are there specific areas within the participating states that the standard health plans will operate? If yes, please describe.

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7. If a state contracts for the provision of geographically specific standard health plans, please describe how it will assure that enrollees, regardless of location within the state, have choice of at least two standard health plan offerors. Please indicate plans by area.

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8. Please assure that the regional compact’s competitive contracting process complies with the requirements set forth in 42 CFR 600.410. ☐

9. If applicable, please indicate any variations in benefits, premiums and cost sharing, and contracting requirements that may occur as a result of regional differences between the participating regional compact states.

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Contracting Process

States must respond to all of the following assurances. If the state has requested an exception to the competitive process for 2015, the State is providing the following assurances with regard to how it will conduct contracting beginning in program year 2016.

The State assures that it has or will:

(These are mandatory elements. Each box below must be checked to approve Blueprint.)

Left blank intentionally	Assurance: (Indicate with an “X” to signal assurance)
Conducted the contracting process in a manner providing full and open competition including:
45 CFR  92.36(b) Following its own procurement standards in conformance with applicable federal law.	☐
45 CFR 92.36(c) Conducting the procurement in a manner providing full and open competition.	☐
45 CFR 92.36(d) Using permitted methods of procurement.	☐
45 CFR 92.36(e) Contracting with small, minority and women owned firms to the greatest extent possible.	☐
45 CFR 92.36(f) Providing a cost or price analysis in connection with every procurement action.	☐
45 CFR 92.36(g) Making available the Technical specifications for review.	☐
45 CFR 92.36(h) Following policies for minimum bonding requirements.	☐
45 CFR 92.36(i) Including all the required contract terms in all executed contracts.	☐
Included a negotiation of the following elements:
Premiums and cost sharing.	☐
Benefits.	☐
Innovative features, such as:
Care coordination and care management	☐
Incentives for the use of preventive services	☐
Maximization of patient involvement in health care decision making	☐
Other (specify below) Click or tap here to enter text.	☐
Meeting health care needs of enrollees.	☐
Included criteria in the competitive process to ensure:
Local availability of and access to providers to ensure the appropriate number, mix and geographic distribution to meet the needs of the anticipated number of enrollees in the service area so that access to services is at least sufficient to meet the standards applicable under 42 CFR Part 438, Subpart D, or 45 CFR 156.230 and 156.235.	☐
Use of managed care or a similar process to improve the quality accessibility, appropriate utilization and efficiency of services provided to enrollees.	☐
Development and use of performance measures and standards.	☐
Coordination between other Insurance Affordability Programs.	☐
Measures to address fraud, waste and abuse and ensure consumer protections.	☐
Established protections against discrimination including:
Safeguards against any enrollment discrimination based on pre-existing condition, other health status related factors, and comply with the nondiscrimination standards set forth at 42 CFR 600.165.	☐
Established a Medical Loss Ratio of at least 85% for any participating health insurance issuer.
The minimum standard is reflected in contracts	☐

Standard Health Plan Contracting Requirements

States are required to include the standard set of contract requirements that will be incorporated into its Standard Health Plan contracts. Please reproduce in the text box below. Standard Health Plan contracts are required to include contract provisions addressing network adequacy, service provision and authorization, quality and performance, enrollment procedures, disenrollment procedures, noticing and appeals, and provisions protecting the privacy and security of personally identifiable information. However, we have given states a "safe harbor" option of reusing either approved Medicaid or Exchange contracting standards. If the state has adopted this safe harbor, it may fulfill this requirement by simply indicating that Medicaid or Exchange contracting standards will be used.

If the state has adopted this safe harbor, it may fulfill this requirement by simply indicating that Medicaid or Exchange contracting standards will be used.

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Coordination of Health Care Services

Please describe how the state will ensure coordination for the provision of health care services to promote enrollee continuity of care between BHP and Medicaid, CHIP, the Exchange and any other state administered health insurance programs.

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Section 6: Premiums and Cost-sharing

This section of the Blueprint collects information from the state documenting compliance with requirements for establishing premiums and cost-sharing. Additionally, it provides CMS general information about the states planned premium and cost sharing structures and administration.

Premiums

Premium Assurances

The State assures that (check all that apply):

☐ The monthly premium imposed on any enrollee does not exceed the monthly premium the individual would have been required to pay had he/she been enrolled in the applicable benchmark plan as defined in the tax code.

☐ When determining premiums, the State has taken into account reductions in the premium resulting from the premium tax credit that the enrollee would have been paid if he/she were in the Exchange.

☐ It will make the amount of premiums for all standard health plans available to any member of the public either through posting on a website or upon request. Additionally, enrollees will be notified of premiums at the time of enrollment, reenrollment or when premiums change, along with ways to report changes in income that might affect premiums.

Please provide the web address or other source for public access to premiums.

Web Address:

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Other Source:

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Please describe:

1. The group(s) of enrollees subject to premiums, including any variation by FPL, and the applicable premiums.

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2. The collection method and procedure for the payment of premiums.

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3. The consequences for an enrollee or applicant who does not pay a premium, including grace periods and re-enrollment procedures.

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Cost-Sharing

Cost-Sharing Assurances

The State assures that (check all that apply):

☐ Cost sharing imposed on enrollees meets the standards imposed by 45 CFR 156.420(c), 45 CFR 156.420(e), 45 CFR 156.420(a)(1) and 45 CFR 156.420(a)(2).

☐ Cost sharing for Indians meets the standards of 45 CFR 156.420(b)(1) and (d).

☐ The State has not imposed cost sharing for preventive health services or items as defined in accordance with 45 CFR 147.130.

☐ The State has provided the amount and type of cost-sharing for each standard health plan that is applicable to every income level either on a public website or upon request to any member of the public, and specifically to applicants at the time of enrollment, reenrollment or when cost-sharing and coverage limitations change, along with ways to report changes in income that might affect cost-sharing amounts.

Please provide the web address or other source for public access to cost-sharing rules.

Web Address:

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Other Source:

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Please describe:

1. The group(s) subject to cost sharing.

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2. All copayments, co-insurance, and deductibles, by service.

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3. The system in place to monitor compliance with cost-sharing protections described above.

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Disenrollment Procedures for Non-Payment of Premiums

Has the state elected to offer the enrollment periods equal to the Exchange defined at 45 CFR 155.410 and 420?

If yes, check the box on the right to indicate the state assures that it will comply with the premium grace periods standards at 45 CFR 156.270 prior to disenrollment and that it will not restrict reenrollment beyond the next open enrollment period.	☐
If no, check the box on the right to indicate the state assures that it is providing a minimum grace period of 30 days for the payment of any required premium prior to disenrollment and that it will comply with reenrollment standards set forth in 457.570(c).	☐

If the state is offering continuous enrollment and is imposing a premium lock-out period, the lock-out period in number of days is:

Enter number of days.

Section 7: Operational Assessment

The State assures that it can or will be able to:

Left blank intentionally	Full Assurance (Indicate with an “X” to signal assurance)	Contingent Assurance (Indicate with an “X” to signal assurance)
Eligibility and Renewals
Accept an application online, via paper and via phone and provide in alternative formats in accordance with 42 CFR §600.310(b).	☐	☐
Return an accurate and timely eligibility result for all BHP eligible applicants.	☐	☐
Process a reported change and redetermine eligibility.	☐	☐
Comply with the ex-parte renewal process.	☐	☐
Issue an eligibility notice and share such notice with CMS.	☐	☐
Issue a renewal notice and share such notice with CMS.	☐	☐
Ability to terminate/disenroll from BHP for a variety of reasons, such as reaching age 65, obtaining MEC.	☐	☐
Issue termination/disenrollment notice to enrollees.	☐	☐
Benefits and Cost-Sharing
Exempt American Indians from Cost-sharing.	☐	☐
Apply appropriate cost-sharing amounts to enrollees subject to cost-sharing limits.	☐	☐
Premium Payment and Plan Enrollment
Issue an accurate and timely premium invoice.	☐	☐
Receipt and apply the premium payment correctly.	☐	☐
Notify enrollee of health plan choices and complete plan enrollment.	☐	☐
Issue a health plan disenrollment notice.	☐	☐
Coordinate enrollment with other Insurance Affordability Programs
Transfer accounts and provide notification in accordance with 42 CFR 600.330(c) through (e).	☐	☐

Contingency Descriptions

Please describe the contingency or dependency that limit full assurance.

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Please describe any mitigation steps that will be in place and the date by which a full assurance will be possible.

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Section 8: Standard Health Plan

This final section of the BHP Blueprint is a benefits description that allows a state to define the standard health plan(s) that will be offered under the BHP. The standard health plan is the set of benefits, including limitations on those benefits for which a state will contract. States are required by statute to offer the Essential Health Benefits (EHB) that are equally required in the Marketplace. States are also required to define those benefits using any of the base-benchmark or reference plans set forth at 45 CFR 156.100 (which could be a different base-benchmark or reference plan than is used for Marketplace or for Medicaid purposes). The benefits description below maps the base-benchmark plan to the EHB categories.

The Blueprint will not be a complete submission without the benefits description below defining the standard health plan offered under BHP.

Standard Health Plan

State Name:

Transmittal Number: Click or tap here to enter text.

Benefits description

The state is proposing to use a CMS approved EHB based plan.

Section 9: Secretarial Certification

Interim Certification:

Secretary/Secretary’s Designee

Click or tap here to enter text.

Director

Center for Medicaid and CHIP services

Date of Official Interim Certification: Click or tap to enter a date.

Implementation Date: Click or tap to enter a date.

Full Certification:

Secretary/Secretary’s Designee

Click or tap here to enter text.

Director

Center for Medicaid and CHIP services

Date of Official Full Certification: Click or tap to enter a date.

Implementation Date: Click or tap to enter a date.

Revised Certification:

Secretary/Secretary’s Designee

Click or tap here to enter text.

Director

Center for Medicaid and CHIP services

Date of Revised Certification: Click or tap to enter a date.

Implementation Date: Click or tap to enter a date.

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