Readers Guide to Sample Health Care Benefits Packages Under the Affordable Care Act (ACA), starting on January 1, 2014, Medicaid eligibility will expand to include all individuals under 133% of the federal poverty. 1 Most newly eligible individuals will be covered under benchmark plans. These ACA benefits packages have not been fully developed by federal regulations and state legislation. Therefore, their extent and scope in any given state are not known in detail. However, previous regulatory treatment of benchmark plans may provide some insight as to how ACA benchmark plans might be implemented. Under earlier Medicaid reforms, Congress authorized states to develop benchmark plans in which to enroll certain groups of Medicaid-eligible individuals. Few states opted to create benchmark plans. Nonetheless, current law provides for benchmark plans benefits packages offering medical coverage that is less comprehensive than full Medicaid benefits, easing a state s financial burden with respect to covering less medically needy individuals. 2 Implementing this pre-aca reform, Medicaid made clear in regulations that even if a state adopts benchmark plans, certain populations would be exempt from benchmark plans. 3 Exempt populations include individuals with serious emotional disturbances, disabling mental disorders, and physical and/or mental disabilities that prevent them from performing one or more tasks of daily living. 5 States are responsible for specifying how individuals will be identified to fall into these categories. States may offer benchmark coverage to this population so long as they are able to clearly compare the benefits of both standard and benchmark plans. 2 Depending on need, it might be more beneficial for an exempt individual to enroll in a benchmark plan, for instance, if her state s usual Medicaid benefits do not cover mental health. This is because benchmark plans must provide mental health in parity to medical and surgical. 5 On the other hand, it might be less beneficial the individual needs community-based like psychiatric rehabilitation, since benchmark plans would likely not include these benefits. 7 Sample Health Benefit Packages For an initial understanding of what this might mean for at-risk adults, the Alliance looked at the specific statutory language and created a chart to show possible variations in coverage, and to note commonly-used terms in health benefits packages. The first column summarizes standard Medicaid benefits under Title 19 (Medicaid) of the Social Security Act as well as several of the optional benefits offered by many states (italicized). Note: By statute, inpatient psychiatric in institutions for mental diseases are not covered for adults under 65 years of age. 8 The ACA does not specify how such are treated for newly-eligible beneficiaries. 1
The second column lists benchmark-equivalent requirements in effect now for certain groups of enrollees in states that adopted benchmark plans prior to the ACA. Under the ACA, those newly eligible under the expansion of Medicaid will also be offered benchmark benefit packages through their state. Note: ACA benchmark plans must include mental health. The third column presents essential ACA health benefits, as described in the enacted legislation. The fourth column shows the standard Blue Cross/ Blue Shield benefit plans for federal employees, which can be adopted by the state as a benchmark plan. References: 1. National Academy for State Health Policy and Robert Wood Johnson Foundation. Medicaid s Role in the Exchange. March 25, 2011. 2. 1937(b)(2)(A) of the Social Security Act. 3. Medicaid Program; State Flexibility for Medicaid Benefit Packages, Federal Register, Vol. 75, No. 83, Apr. 30 2010. p. 23096. 4. 1937(b)(2)(B) of the Social Security Act. 5. National Council for Community Behavioral Health. Medicaid Benchmark Benefits in Health Reform: Improvements and Exemptions. November 2010. http://www.napas.org/images/documents/advocacy/legislation/medicaid/medicaid-benchmark- Coverage-Health-Reform.pdf. 6. 1937(b)(6)(A) of the Social Security Act. 7. Bazelon Center for Mental Health Law. Update on Medicaid for Adults. July 2010. 8. 1905(a)(1)-(29) of the Social Security Act. 2
Plans Inpatient hospital Care Medicaid benefits 1, 2 (Social Security Act Title XIX) Sample Health Care Benefit Packages For illustration and comparison only Benchmarkequivalent requirements 3 (DRA regs with ACA amendments) ACA statutory categories of health benefits 4 Hospitalization Inpatient hospital Inpatient hospital Hospitalization Emergency and urgent Emergency Outpatient Outpatient hospital Standard Blue Cross/Blue Shield PPO service benefit plan 5 Annual deductible $300, plus copayment on most items and Inpatient hospital stay and Emergency * (optional) Emergency Emergency Accidental injury Outpatient hospital (including in FQHC and rural health clinic) Physician Physician Laboratory and x-ray Laboratory and x-ray Preventative Care - Early and periodic screening, diagnostic, and treatment (EPSDT) - EPSDT for children <21 - Screening and - Other preventative preventative measures* (optional) Prescription drugs Outpatient hospital Physicians' surgical and medical Laboratory and x-ray - EPSDT - All other appropriate preventative, as designated by the Secretary Ambulatory patient Laboratory Preventative and wellness and chronic disease management General outpatient Lab, x-ray, other diagnostic tests Routine physical exams, cancer diagnostic + screening tests, immunizations Prescribed drugs* (optional) Prescription drugs Prescription drugs Level I (generic drug) Level II & III (brand name) 3
Plans Other Medicaid benefits 1, 2 (Social Security Act Title XIX) Benchmarkequivalent requirements 3 (DRA regs with ACA amendments) ACA statutory categories of health benefits 4 Standard Blue Cross/Blue Shield PPO service benefit plan 5 Annual deductible $300, plus copayment on most items and Rehabilitative and habilitative + devices Physical, occupational, speech, language, and hearing therapy * (optional) Not specified Rehabilitative and habilitative + devices Physical, occupational, speech, cognitive therapy Setting-specific FQHC, rural health clinic, home health, + nursing facility (over age 21) Access to FQHC + rural health clinic Not specified Home health Transportation Non-emergency transportation Not specified Not specified Not specified Case management 10 subcategories: mental health, developmental disabilities, mental retardation, HIV/AIDS, physical disabilities, medically fragile, traumatic brain injury, autism, acquired injury (in order of most adopted in states)* (optional) Not specified Not specified Not specified 4
Plans Mental Health/ Substance abuse Medicaid benefits 1, 2 (Social Security Act Title XIX) Benchmarkequivalent requirements 3 (DRA regs with ACA amendments) ACA statutory categories of health benefits 4 Standard Blue Cross/Blue Shield PPO service benefit plan 5 Annual deductible $300, plus copayment on most items and Other Pediatric, including oral + vision Any related to mental health- intermediate facility, targeted case management, inpatient psychiatric (under age 21), inpatient institutions (over age 65)* (optional) Optometry and Audiology * (optional) Mental health at parity with medical and surgical coverage** (see Wellstone-Domenici Parity Act) Visual, hearing * (optional) Mental health and substance use disorder, including behavioral health treatment Pediatric, including oral + vision Professional MH MH inpatient professional visits + intensive outpatient Hearing and vision Maternity and newborn Freestanding birth center, nurse midwife, nurse practitioner, tobacco cessation counseling and pharmacotherapy for pregnant women Well-baby and well-child, including ageappropriate immunizations Maternity and newborn Complete maternity Family Planning Family planning and supplies Family planning, supplies Not specified Family planning ** Wellstone-Domenici Parity Act of 2008 - Any plan providing both mental health and substance abuse coverage and medical and surgical coverage must treat them equally in terms of out of pocket costs and benefit limits (http://www.hhs.gov/news/press/2010pres/01/20100129a.html) 5
Sources: 1. Medicaid and CHIP Payment and Access Commission (MACPAC). Report to the Congress on Medicaid and CHIP. March 2011. p. 33. http://www.macpac.gov/reports 2. 1905(a)(1)-(29) of the Social Security Act. 3. 1937(b)(2)(A) of the Social Security Act. 4. 1302(b) of the Affordable Care Act. 5. Blue Cross and Blue Shield Federal Employee Program. Blue Cross and Blue Shield Service Benefit Plan. 2010. http://www.fepblue.org/benefitplans/2010-sbp/bcbs-2010-ri71-005.pdf 6. http://www.thenationalcouncil.org/galleries/policy-file/medicaid%20benchmark%20coverage%20health%20reform.pdf 6