Guidance History
| Date | Description of Change |
|---|---|
| 2/17/2017 | Original guidance issued |
| 1/15/2021 | Clarified language on types of alternative benefit plans (for regular ACA adult expansion population and for the medically frail ACA adult expansion population) |
Brief Issue Description
This document outlines the challenges states have faced when reporting eligibles enrolled in an Alternative Benefit Plan (ABP) in their T-MSIS submissions and recommends guidance for states’ reporting.
Background Discussion
Context
The Deficit Reduction Act of 2005[1] modified Section 1937 of the Social Security Act[2] to offer states new Medicaid benchmark and benchmark-equivalent benefit package options, affording states more flexibility in designing Medicaid benefit packages for specific populations. Now known as Alternative Benefit Plans (ABPs), these plans predominantly cover childless adult Medicaid-expansion populations (that is the VIII group) as specified under the Affordable Care Act, but states have and continue to use them as a coverage option for other eligibility groups. States can carefully target the needs of specific populations by offering multiple ABPs, each suited to the needs of the eligible populations. ABPs can be administered via one or more delivery systems including fee-for- service Medicaid, Medicaid managed care, and commercial insurance.
Challenge
It is important to identify individuals enrolled in an ABP so they can be distinguished from other Medicaid eligibles who have either a broader or more limited benefit package. Limited options exist in T-MSIS for identifying ABP eligibles and their associated claims; therefore, it is important to use the few options that are available consistently and accurately. Since enrollment in ABPs is voluntary for some populations, demographics and eligibility criteria are not always specific enough to reliably identify ABP enrollees. If a state offers multiple ABPs to overlapping populations, it is also important to identify the specific ABP in which an eligible is enrolled.
If eligibles are enrolled in an ABP, then the ABP is their default Medicaid benefit plan, including optional wraparound services, so the ABP would cover all of their claims. Therefore, flagging the claims as ABP is redundant when eligibility information for eligibles enrolled in an ABP can reliably be linked to claims.
CMS Guidance
When identifying an ABP eligible, it is important to consider five data elements:
In the ELIGIBLE file, for adult Medicaid Expansion eligibles who are not medically frail:
- RESTRICTED-BENEFITS-CODE should be set to “7” (Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.)
- STATE-PLAN-OPTION-TYPE should be set to “06” (1937 (Alternative Benefit Plans))
- STATE-SPEC-ELIG-GROUP should indicate the ABP subpopulation and/or the eligible’s specific benefit package.
- ELIGIBILITY-GROUP for most ABPs is primarily the adult expansion population defined by values “72”, “73”, “74”, and “75”
In the ELIGIBLE file, for adult Medicaid Expansion eligibles who are medically frail and who have opted for the full-Medicaid benefit APB rather than the limited/restricted ABP available to non-medically frail adult Medicaid expansion eligibles:
- RESTRICTED-BENEFITS-CODE should be set to “1” (Individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits).
- STATE-PLAN-OPTION-TYPE should be set to “06” (1937 (Alternative Benefit Plans))
- STATE-SPEC-ELIG-GROUP should indicate the ABP subpopulation and/or the eligible’s specific
- benefit package.
- ELIGIBILITY-GROUP for adult Medicaid Expansion eligibles who are medically frail are defined by values “72”, “73”, “74”, and “75”
In the MANAGED CARE PLAN file:
- OPERATING-AUTHORITY should be set to “10” (1937benchmark benefit program—programs to provide benefits that differ from Medicaid state plan benefits using managed care and implemented through the state plan) if the ABP is delivered through a managed care plan.
Adult Medicaid expansion eligibles who are not medically frail are required to be covered by an alternative benefit plan, as opposed to some other set of benefits such as full-Medicaid benefits. For adult Medicaid expansion eligibles who are medically frail, they must be given the option to choose either the limited/restricted ABP available to the adult Medicaid expansion population that is not medically frail or the full-Medicaid benefit APB.[3] Therefore, all eligibles that are not medically frail reported with ELIGIBILITY- GROUP values “72”, “73”, “74”, or “75” (all representing adult Medicaid expansion populations) are expected to be reported with RESTRICTED-BENEFITS-CODE “7” and STATE-PLAN-OPTION-TYPE “06”. Adult Medicaid expansion eligibles who are medically frail and who have opted for the full-Medicaid benefit APB reported with ELIGIBILITY-GROUP values “72”, “73”, “74”, or “75” (all representing adult Medicaid expansion populations) are expected to be reported with RESTRICTED-BENEFITS-CODE “1” and STATE-PLAN-OPTION-TYPE “06”.
To ensure that all ABP-eligibles are properly captured in the data, states implementing expansions through 1115 waivers should follow these same coding guidelines for RESTRICTED-BENEFITS-CODE and STATE-PLAN-OPTION-TYPE. This is recommended even though these waiver enrollees might otherwise be mapped to RESTRICTED-BENEFITS-CODE ‘1’ or ‘5’ (due to the greater flexibility under the waiver) and STATE-PLAN-OPTION- TYPE would otherwise not be applicable.
As of February 2017 there are six states (IA, ID, IN, KY, MA, and MT) with multiple ABPs. Those six states should carefully consider how they can use the STATE-SPEC-ELIG-GROUP to distinguish under which specific ABP an individual is covered. CMS is considering future changes to the T-MSIS layout to capture this in a more uniform manner.
The following table lists relevant excerpts from the T-MSIS data dictionary pertaining to the five germane data elements.| FILE SEGMENT (with RECORD ID) | DATA ELEMENT NUMBER | DATA ELEMENT NAME | DATA ELEMENT DEFINITION | VALID VALUE DEFINITION |
|---|---|---|---|---|
| ELIGIBILITY- DETERMINANTS- ELG00005 | ELG087 | ELIGIBILITY- GROUP | The eligibility group applicable to the individual based on the eligibility determination process. The valid value list of eligibility groups aligns with those being used in the Medicaid and CHIP Program Data System (MACPro). |
72 - Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states 73 - Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states 74 - Adult Group - Individuals at or below 133% FPL Age 19 through 64 – not newly eligible parent/ caretaker-relative(s) in 1905z(3) states 75 - Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non- parent/ caretaker-relative(s) in 1905z(3) states |
| ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093 | STATE-SPEC-ELIG-GROUP |
The composite of eligibility mapping factors used to create the corresponding Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) values. This field should not include information that already appears elsewhere on the Eligible-File record even if it is part of the MAS and BOE algorithm (e.g., age information computed from DATE-OF-BIRTH or COUNTY-CODE). |
Defined by the state |
| ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097 | RESTRICTED-BENEFITS-CODE | A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to. |
1 - Individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits 7 – Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005. |
| STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG163 | STATE-PLAN-OPTION-TYPE | This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment. | 06 – 1937 (Alternative Benefit Plans) |
| MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR067 | OPERATING-AUTHORITY | The type of operating authority through which the managed care entity receives its contract authority. | 10 – 1937 benchmark benefit program—programs to provide benefits that differ from Medicaid state plan benefits using managed care and implemented through the state plan. |
Note: The specified valid values for RESTRICTED-BENEFITS-CODE, STATE-PLAN-OPTION-TYPE, and OPERATING-AUTHORITY all represent the same thing – applicability of Alternative Benefit Plan’s defined by Social Security Act Section 1937.
[1] See Deficit Reduction Act of 2005