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.

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.

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.

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.

Verification services that are conducted as part of the eligibility determination process or to validate a client's attestation, after an eligibility record has been entered into the system, will be eligible for 75 percent FFP.

Those verifications performed post eligibility and normally initiated as part of a sampling approach, including audits, PERM or MEQC activities would be considered program integrity activity and eligible for the 50 percent FFP.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

No. Under section 438.356 of the Final Rule, states can contract with one or more EQROs to conduct EQR activities and other related tasks (such as production of the EQR report).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

Use our dentist locator to find a dentist that accepts Medicaid.

The ASD-related services for EPSDT eligible individuals (under age 21) must be provided under the Medicaid state plan and not under the 1915(c) waiver. When the state submits the home and community-based services waiver for renewal or amendment, the state should include a restriction under the "limits" section for that specific service indicating that EPSDT-aged individuals are excluded as the services are fully covered in the state plan. ASD-related services for individuals over age 21 may continue to be provided under the 1915(c) waiver.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

Alignment with the state's system development life cycle happens during the Project Initiation phase, specifically during Activity 1: Consult with CMS. The state should incorporate CMS milestone reviews into the state's project schedule. The flexibility is in scheduling, not whether milestone reviews are performed. Decisions made between the state and CMS are documented in the Project Partnership Understanding document and can be updated as needed throughout the life cycle.

At a minimum, quarterly. Depending on the risk of project activity, the state and CMS may agree that more frequent reporting is appropriate. Any frequency greater than quarterly should be captured in the Project Partnership Understanding document.