Frequently Asked Questions

Since 2006, State Medicaid programs have had the option to provide certain groups of Medicaid enrollees with an alternative benefit package known as "benchmark" or "benchmark-equivalent" coverage, based on one of three commercial insurance products or a fourth, "Secretary-approved" coverage option. Beginning on January 1, 2014, all Medicaid benchmark and benchmark-equivalent plans must include at least the ten statutory categories of Essential Health Benefits. Under the Affordable Care Act, the medical assistance provided to the expansion population of adults who become newly eligible for Medicaid as of January 1, 2014, must be provided consistent with section 1937 benchmark authority.

For Medicaid alternative benefit plans, three of the benchmark plans described in section 1937 (the State's largest non-Medicaid HMO, the State's employee health plan, and the FEHBP BCBS plan) may be designated by the Secretary as EHB benchmark reference plans, as described in the EHB Bulletin (link below). A State Medicaid Agency could select any of these section 1937 benchmark plans as its EHB benchmark reference plan for Medicaid. There would be no default EHB benchmark reference plan for purposes of Medicaid; each State Medicaid Agency would be required to identify an EHB benchmark reference plan for purposes of Medicaid as part of its 2014-related Medicaid State Plan changes.

If the EHB benchmark reference plan selected for Medicaid were to lack coverage within one or more of the ten statutorily-required categories of benefits, the section 1937 alternative benefit plan would need to be supplemented to ensure that it provides coverage in each of the ten statutory benefit categories. This would be in addition to any other requirements for Section 1937 plan, including Mental Health Parity and Addition Equity Act compliance.

For more information about the Essential Health Benefits, please see CCIIO's bulletin from December 2011 (available at http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf ) and the CMCS informational bulletin from February 2012 (available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-02-17-12.pdf (PDF, 71.68 KB).

FAQ ID:93036

Yes. A State is not required to select the same EHB benchmark reference plan for Medicaid section 1937 plans that it selects for the individual and small group market, and it could have more than one EHB benchmark reference plan for Medicaid (for example, if the State were to develop more than one benefit plan under section 1937).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 70.98 KB)

FAQ ID:93041

Yes. A State could propose its traditional Medicaid benefit package as a section 1937 alternate benefit plan under the Secretary-approved option available under section 1937 of the Social Security Act. The State would have to ensure that the ten statutory categories of EHB are covered, either through that benefit plan or as a supplement to that plan.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 70.98 KB)

FAQ ID:93046

The managed care regulations apply to all benefits delivered through a managed care delivery system, regardless of the authority under which the benefits are provided or enrollment is required. Thus, any State which uses a managed care organization to deliver benefits under the authority of section 1937 of the Act must comply with the managed care regulations at 42 CFR 438.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 70.98 KB)

FAQ ID:93051

Yes. 1915 (c) waivers are optional programs that most States currently operate and can continue to operate. States interested in making changes to their 1915(c) waivers should contact their CMS Regional Office with specific questions.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 70.98 KB)

FAQ ID:93056

In section 156.100 of the proposed rule on Essential Health Benefits/Actuarial Value/Accreditation, we propose criteria for the selection process for a state that chooses to select a benchmark plan. The essential health benefits benchmark plan would serve as a reference plan, reflecting both the scope of services and limits offered by a typical employer plan in that state. This approach and benchmark selection, which would apply for at least the 2014 and 2015 benefit years, would allow states to build on coverage that is already widely available, minimize market disruption, and provide consumers with familiar products. Since some base-benchmark plan options may not cover all ten of the statutorily required essential health benefits categories, we propose standards for supplementing a base-benchmark plan that does not provide coverage of one or more of the categories.

We also propose that if a base-benchmark plan option does not cover any items and services within an essential health benefits category, the base-benchmark plan must be supplemented by adding that particular category in its entirety from another base-benchmark plan option. The resulting plan, which would reflect a base-benchmark that covers all ten essential health benefits categories, must meet standards for nondiscrimination and balance. After meeting these standards, it would be considered the essential health benefits-benchmark plan.

The proposed rule also outlines the process by which HHS would supplement a default base-benchmark plan, if necessary. We clarify that to the extent that the default base-benchmark plan option does not cover any items and services within an essential health benefits category, the category must be added by supplementing the base-benchmark plan with that particular category in its entirety from another base-benchmark plan option. Specifically, we propose that HHS would supplement the category of benefits in the default base benchmark plan with the first of the following options that offer benefits in that particular essential health benefits category: (1) the largest plan by enrollment in the second largest product in the state's small group market; (2) the largest plan by enrollment in the third largest product in the state's small group market; (3) the largest national Federal Employees Health Benefit Program plan by enrollment across states that is offered to federal employees; (4) the largest dental plan under the Federal Employees Dental and Vision Insurance Program, for pediatric oral care benefits; (5) the largest vision plan under the Federal Employees Dental and Vision Insurance Program, for pediatric vision care benefits; and (6) habilitative services as described in section 156.110(f) or 156.115(a)(4).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)

FAQ ID:94466

The U.S. Office of Personal Management released a proposed rule implementing the Multi-State Plan Program on November 30, 2012. To ensure that the Multi-State Plans are competing on a level playing field with other plans in the marketplace, the proposed regulation largely defers to state insurance law and the standards promulgated by HHS and states related to qualified health plans. Under the proposal, Multi-State Plans will be evaluated based largely on the same criteria as other qualified health plans operating in Exchanges. The few areas in which the Office of Personal Management proposes different regulatory standards from those applicable to qualified health plans are areas where the Office of Personal Management has extensive experience through its administration of the Federal Employees Health Benefits Program. However, in order to ensure that these few differences will not create any unfair advantages, the Office of Personal Management seeks comment from states and other stakeholders on these proposals. The regulation appeared in the Federal Register on December 5, 2012, and the comment period runs through January 4, 2013.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)

FAQ ID:94471

It depends on the individual state plan amendment, but if a state submitted a state plan amendment to cover the relevant DME at or below what Medicare would pay for the same items and that was effective January 1, 2018, then a state would be considered to have demonstrated compliance with the statute and be exempt from submitting a DME FFP limit demonstration. If the state does not currently use Medicare’s payment rates (or a lesser percentage thereof) to reimburse providers for DME, the state may submit a SPA to alter its DME reimbursement methodology to set rates at or below the applicable Medicare rates. If there are competitive bidding areas (CBAs) in the state as defined by Medicare, it may choose to either pay the competitive bidding single payment amount for DME in the applicable CBA of the state under the Medicare program, or could set the statewide plan rate at the lesser of the durable medical equipment, prosthetics, orthotics and supplies fee schedule rate, including rural and non-rural areas as defined by Medicare, or the competitive bid single payment amount under the Medicare CBA for the item. States should be aware that if a SPA is submitted to align Medicaid payment rates to Medicare and is effective after January 1, the Centers for Medicare & Medicaid Services (CMS) will require the submission of a demonstration for the year in which a SPA is submitted to ensure compliance with the statute for a full calendar year. Once payment rates are set at Medicare rates for a full calendar year, CMS will consider the state as being compliant with the statute through the state plan.

FAQ ID:93551

In general, public notice is required for any changes in statewide methods and standards for setting payment rates as described in 42 CFR 447.205. Public notice must be published one day prior to the effective date of the SPA. If there are specific questions about this policy, please contact the Medicaid durable medical equipment team by email at: MedicaidDME@cms.hhs.gov.

FAQ ID:93556

A simple statement by a state that its payments for DME will not exceed the FFP limit would not be adequate. The statute establishes a limit on the Secretary’s ability to pay FFP, and we must follow the statutory restrictions. We have discussed two potential approaches that a state might use in the January 4, 2018 letter. Any state that wishes to discuss alternative approaches under the State Medicaid Director Letter should contact the Medicaid DME team with all of the information relevant to their request as early in the year as possible.

FAQ ID:93561