Traditional Versus Benchmark Benefits
Under Medicaid
Elicia J. Herz
Specialist in Health Care Financing
August 3, 2012
Congressional Research Service
7-5700
www.crs.gov
R42478
CRS Report for Congress
Pr
epared for Members and Committees of Congress

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Traditional Versus Benchmark Benefits Under Medicaid

Summary
The Medicaid program, which served 69 million people in FY2011, finances the delivery of a
wide variety of preventive, primary and acute care services as well as long-term services and
supports for certain low-income populations. Benefits are available to beneficiaries through two
avenues. First, the traditional Medicaid program covers a wide variety of mandatory services
(e.g., inpatient hospital services, lab/x-ray services, physician care, nursing facility care for
persons aged 21 and over) and other services at state option (e.g., prescribed drugs, physician-
directed clinic services, physical therapy, prosthetic devices) to the majority of Medicaid
beneficiaries across the United States. Within broad federal guidelines, states define the amount,
duration, and scope of these benefits. Thus, even mandatory services are not identical from state-
to-state.
The Deficit Reduction Act of 2005 (DRA; P.L. 109-171) created an alternative benefit structure
for Medicaid. Under this authority, states may enroll certain Medicaid subpopulations into
benchmark benefit plans that include four choices: (1) the standard Blue Cross/Blue Shield
preferred provider plan under the Federal Employees Health Benefits Program, (2) a plan offered
to state employees, (3) the largest commercial health maintenance organization in the state, and
(4) other coverage appropriate for the targeted population, subject to approval by the Secretary of
Health and Human Services (HHS).
Since the enactment of the Patient Protection and Affordable Care Act in 2010 (ACA; P.L. 111-
148, as amended), benchmark benefits have taken on a new importance in the Medicaid program.
As per the ACA, a new mandatory group of non-elderly, non-pregnant adults with income up to
133% of the federal poverty level will be eligible for Medicaid beginning in 2014, or sooner at
state option. (For more information about a recent Supreme Court ruling regarding this group, see
CRS Report RL33202, Medicaid: A Primer.) These individuals will be required to enroll in
benchmark plans rather than traditional Medicaid (with some exceptions for subgroups with
special medical needs). However, to date, only a handful of states have experience administering
these plans, nearly all of which have been tailored to specific subpopulations.
The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) estimated
that coverage expansion provisions in the ACA would increase enrollment by about 7 million in
FY2014, rising to 11 million by FY2022 in both the Medicaid and the State Children’s Health
Insurance Programs (Congressional Budget Office, Estimates for the Insurance Coverage
Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision, July
2012). Many of these new enrollees will get benchmark benefits. To assist Congress in evaluating
the current scope of benefits available under Medicaid, this report outlines the major rules that
govern and define both traditional Medicaid and benchmark benefits. It also compares the
similarities and differences between these two benefit package designs.

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Traditional Versus Benchmark Benefits Under Medicaid

Contents
Medicaid Eligibility ......................................................................................................................... 1
Traditional Medicaid Benefits ................................................................................................... 3
Medicaid Benchmark Benefit Packages .................................................................................... 5
Mental Health Parity Requirements Under Both Traditional Medicaid and Benchmark
Plans ....................................................................................................................................... 7
State Experience with Medicaid Benchmark Packages............................................................. 7
Additional CRS Medicaid and CHIP Resources ..................................................................... 13

Tables
Table 1. Examples of Medicaid Benefits by Eligibility Classification ............................................ 2
Table 2. Examples of Frequently Covered Optional Benefits Under Traditional Medicaid
as of August 13, 2010 ................................................................................................................... 4
Table 3. Statutory and Regulatory Exceptions to Mandatory Enrollment
in Medicaid Benchmark Benefit Plans ......................................................................................... 5
Table 4. Selected Characteristics of Medicaid Benchmark Plans.................................................... 9

Contacts
Author Contact Information........................................................................................................... 13

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Traditional Versus Benchmark Benefits Under Medicaid

edicaid was established in 1965 to provide basic medical services to certain
low-income populations. It is a means-tested entitlement program that financed the
M delivery of primary and acute medical services, as well as long-term services and
supports, to more than an estimated 69 million people in FY2011.1 The estimated annual cost to
the federal and state governments for Medicaid was nearly $404 billion in FY2010.2
Each state designs and administers its own version of Medicaid under broad federal rules. State
variability is the rule rather than the exception in terms of eligibility levels, covered services, and
how those services are delivered and reimbursed.
Not everyone enrolled in Medicaid has access to the same set of services. Different eligibility
classifications determine available benefits, as described below. This report begins with a
summary of major Medicaid eligibility pathways. Then traditional Medicaid benefits and
benchmark coverage are described. The final section provides an analysis of state experiences
with benchmark benefit packages as of early 2011. Additional CRS resources on the Medicaid
and Children’s Health Insurance Program are provided at the end of this report.
Medicaid Eligibility
Historically, eligibility for Medicaid was subject to “categorical restrictions” that generally
limited coverage to the elderly, persons with disabilities, members of families with dependent
children, certain other pregnant women and children, among others. Recent changes in federal
law established Medicaid eligibility for poor non-elderly, childless adults who do not fit into these
traditional categories; states may cover such individuals now, but coverage of this new group will
become mandatory beginning in 2014.
In addition, to qualify for Medicaid, applicants must have income (and sometimes assets) that
meet financial requirements. These financial criteria are typically tied to certain federal cash
assistance program rules or to specific percentages of the federal poverty level (FPL).3
Below is a description of services available for Medicaid beneficiaries by eligibility
classification. First, “categorical needy” individuals represent the vast majority of people enrolled
in Medicaid, most of whom receive traditional Medicaid benefits (described in more detail
below). The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended)
requires that a newly established categorically needy group consisting of poor nonelderly, non-
pregnant adults with income below 133% FPL receive Medicaid benchmark benefits, an
alternative to traditional Medicaid benefits. However, on June 28, 2012, the United States
Supreme Court issued a decision in National Federation of Independent Business v. Sebelius. The
Court held that the federal government cannot terminate current Medicaid federal matching funds
if a state refuses to expand its Medicaid program to include non-elderly, non-pregnant adults

1 Beneficiary statistics for FY2011 were taken from Table 1.16, 2011 CMS Statistics, U.S. Department of Health and
Human Services.
2 Expenditure statistics for FY2010 were taken from Table III.2, 2011 CMS Statistics, U.S. Department of Health and
Human Services.
3 For example, pregnant women and children under age 6 with family income below 133% of FPL are mandatory
eligibility groups under Medicaid. In 2012, the FPL for a family of four is $23,050—133% of FPL for a family of four
would equal $30,656.50. See http://aspe.hhs.gov/poverty/12poverty.shtml.
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under 133% of the federal poverty level. If a state accepts the new ACA Medicaid expansion
funds, it must abide by the new expansion coverage rules, but based on the Court’s opinion, it
appears that a state can refuse to participate in the expansion without losing any of its current
Medicaid matching funds.4
Other benefit rules apply to individuals classified as “medically needy,” including people who
meet the main categorical restrictions described above but may have higher income. States
electing the medically needy option must provide coverage to certain pregnant women and
children under age 18. For the medically needy, states may offer a more restrictive benefit
package than is available to most categorically needy individuals.
Finally, states also use the authority in Section 1115 of the Social Security Act to tailor benefits to
state-specified subpopulations that can include both currently authorized groups and/or new
groups not specified in federal statute. Each such waiver delineates the unique terms and
conditions that are negotiated between a given state and the federal Centers for Medicare &
Medicaid Services (CMS).5
Table 1 provides examples of Medicaid benefits available by selected eligibility classifications.
As illustrated, different Medicaid subpopulations may have access to benefit packages that can be
quite varied. Additional details are described further below.
Table 1. Examples of Medicaid Benefits by Eligibility Classification
Type of Benefit
and Benefit
Package Eligibility
Classification
Type of Benefit
Categorically Needy
Medically Needy
Section 1115
Non-Elderly, Non-
(excluding Non-
Waivers
Pregnant Adults
Elderly, Non-
Pregnant Adults)
Mandatory -Inpatient
hospital
-Prenatal and
-Negotiated between -Benchmark plans
delivery services
the states and the
-Nursing facility care
Secretary of Health
(age 21+)
-Ambulatory services and Human Services
(< age 18; persons
-EPSDT (< age 21)
(HHS)
entitled to
-Physicians
institutional care)
-Federally-qualified
-Home health for
health centers
those entitled to
nursing facility care
-Family planning
-Pregnancy-related
services
Optional -Clinic
services
-Nursing facility care
-Negotiated between -For special needs
the states and
subgroups, option to
-Prescribed drugs
-Clinic services

4 For a more detailed discussion, see the CRS Congressional Distribution Memo, Selected Issues Related to the Effect
of NFIB v. Sebelius on the Medicaid Expansion Requirement in Section 2001 of the Affordable Care Act, by Kathleen
S. Swendiman and Evelyne P. Baumrucker. Also see http://www.crs.gov/analysis/legalsidebar/pages/details.aspx?
ProdId=117 and http://www.crs.gov/analysis/legalsidebar/pages/details.aspx?ProdId=121.
5 For additional information about Section 1115 waivers, see CRS Report RL33202, Medicaid: A Primer.
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Traditional Versus Benchmark Benefits Under Medicaid

Type of Benefit
and Benefit
Package Eligibility
Classification
-Physical,
-Physical,
Secretary of HHS
have same benefits
occupational, and
occupational, and
as categorically
speech therapy
speech therapy
needy or enroll in
benchmark plan
-Other practitioners
-Other practitioners
-Dental
-Dental
Traditional Benefits
Traditional Benefits
Traditional Benefits
Not applicable
Benchmark plans
Versus Benchmark
with exceptions; see
Package
Table 3 for details
Sources: Title XIX of the Social Security Act and related federal guidance.
Note: With respect to medically needy groups, broader requirements apply if a state has chosen to provide
coverage for medically needy individuals in intermediate care facilities for the mentally retarded or in institutions
for mental diseases. In these cases, states are required to cover either the same services as those which are
mandatory for the categorically needy, or alternatively, the care and services described in seven of the first
twenty-four paragraphs in the federal Medicaid statute defining covered mandatory and optional services. EPSDT
means “early and periodic screening, diagnostic and treatment.” This benefit includes well-child visits,
immunizations, lab tests, as well as vision, dental and hearing screening services at regular intervals.
Traditional Medicaid Benefits
Like eligibility, under traditional Medicaid, states must cover certain benefits, while other
services may be offered at state option. Examples of benefits that are mandatory for most
Medicaid groups (i.e., categorically needy populations) include inpatient hospital services,
physician services, laboratory and x-ray services, early and periodic screening, diagnostic and
treatment services (EPSDT) for individuals under 21,6 nursing facility services for individuals
aged 21 and over, and home health care for those entitled to nursing facility care. Examples of
optional benefits for such Medicaid groups include prescribed drugs, physician-directed clinic
services, services of other licensed practitioners (e.g., chiropractors, podiatrists, psychologists)
services, nursing facility services for individuals under age 21, physical therapy, and prosthetic
devices.
Table 2 provides additional information for selected optional benefits covered by most states
under the traditional Medicaid program.

6 With respect to EPSDT, states also must provide medical care that is necessary to address health problems identified
through screenings, including optional services that states may not otherwise cover in their Medicaid programs.
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Table 2. Examples of Frequently Covered Optional Benefits Under
Traditional Medicaid as of August 13, 2010
Selected Optional
Number of States
Benefits
Offering Benefit
Description of Benefit
Examples of Preventive, Primary and Acute Care Services
Clinic Services
50
A wide range of health care services including services for
prevention or treatment of health conditions or illnesses,
surgery, and other care provided in a centralized facility
Hospice Services
48
Care for persons with illnesses that cannot be cured or fully
treated. Hospice care involves a team of medical
professionals who take care of the medical, physical, social,
emotional and spiritual needs of the patient, and also
support to the patient’s family or caregiver
Occupational Therapy
50
Services to enhance an individual’s participation in, or
performance of, common activities such as eating, dressing,
moving about, working, and going to school
Optometric Services
50
Services from an individual with training to diagnose and
prescribe treatment for diseases of the eye and problems
with vision, and may include eye glasses, lenses, exercises or
referrals for specialized treatment
Physical Therapy
50
Services to restore physical function to a person with a
disability caused by illness, trauma, or birth defects
Prescribed Drugs
50
Drugs that an individual can get only if a doctor (or another
authorized health care provider) gives permission through a
prescription
Speech and Language
49
Services to diagnose and treat speech and language
Therapy
problems
Targeted Case
50
Services to help individuals be independent and learn to
Management
manage their health care, including linking such people with
health care providers, social services, educational services,
etc., based on that person’s needs
Examples of Long-Term Services and Supports
Inpatient Psychiatric
48
Services that a person < age 21 might receive at a hospital
Services for Individuals <
or psychiatric residential treatment facility while staying
Age 21
overnight for treatment of mental illness, and may include
services provided by a physician or nurse, lab work, surgery,
and drugs
Intermediate Care
51
Services at a facility that provides 24-hour rehabilitative as
Facilities for the Mentally
well as health care and services for persons with
Retarded
developmental disabilities
Nursing Facility Services
50
Skilled nursing, rehabilitation, and other services provided in
for Individuals < Age 21
a facility to assist individuals with illness, injuries, or other
disabilities to recover or improve, and to provide long-term
care to those who need support with daily activities such as
bathing, dressing and eating
Prosthetic Devices
49
Devices to replace, correct or support missing or impaired
portions of the body
Targeted Case
51
Services to help individuals with mental health needs learn
Management for Mental
how to manage their health care
Health
Source: Centers for Medicare & Medicaid Services, derived from www.healthcare.gov and individual state
Medicaid websites as of August 13, 2010, personal communication, fall of 2010.
Note: The definition of state includes the District of Columbia.
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Traditional Versus Benchmark Benefits Under Medicaid

The breadth of coverage for a given benefit can and does vary from state to state, even for
mandatory benefits. In general, in defining a covered benefit, federal guidelines require that (1)
services be sufficient in amount, duration and scope to reasonably achieve their purpose; (2) the
amount, duration, and scope of services must be the same statewide; and (3) with some
exceptions, beneficiaries must have freedom of choice of providers among health care
practitioners or managed care entities participating in Medicaid. States can modify these rules via
existing waiver authority provided in Section 1115 of the Social Security Act.
Medicaid Benchmark Benefit Packages
As an alternative to providing all the mandatory and selected optional benefits under traditional
Medicaid, the Deficit Reduction Act of 2005 (DRA; P.L. 109-171) gave states the option to enroll
state-specified groups in benchmark and benchmark-equivalent benefit packages.7 These plans
can exist in sub-state areas and can be limited to specific subpopulations.
States can require “full benefit eligibles” (or specific subgroups of these individuals) to enroll in
Medicaid benchmark benefits. A full benefit eligible is someone who is eligible for all the
mandatory and optional services that a state covers under its traditional Medicaid program.
Medically needy and certain spend-down populations (e.g., individuals whose Medicaid
eligibility is based on a reduction of countable income for costs incurred for medical or remedial
care) are excluded from the definition of a full benefit eligible. Specific groups are exempt from
mandatory enrollment in benchmark benefit packages (e.g., those with special health care needs
such as disabling mental disorders or serious and complex medical conditions). Table 3 provides
a description of each of these exempted populations.
Table 3. Statutory and Regulatory Exceptions to Mandatory Enrollment
in Medicaid Benchmark Benefit Plans
(i) mandatory pregnant women with income below 133% of the federal poverty level (FPL)
(ii) blind or disabled individuals without regard to whether the individual is eligible for Supplemental
Security Income (SSI) benefits and certain children under age 19 who meet the SSI disability
definition, require an institutional level of care and the expected cost of care outside an appropriate
institution is less than the expected cost that would be incurred within an appropriate institution;
this latter group is sometimes referred to as the Katie Beckett group
(iii) Medicaid beneficiaries entitled to benefits under Medicare
(iv) terminally ill individuals receiving Medicaid hospice benefits
(v) inpatients in an institution who are required to pay for the costs of such care, excluding a
minimal amount required for personal needs (e.g., hair care, clothing, telephone services)
(vi) certain persons who are medically frail or have special needs such as children under age 19
eligible for SSI, or foster care or other out-of-home placement, or those receiving foster care or
adoption assistance, or receiving community-based services through certain Title V Maternal and
Child Health grants
(vii) beneficiaries qualifying for long-term care services (e.g., nursing facility services or similar level
of care in any institution, certain home and community-based waiver services (under Section
1915(c) and (d), and other optional state plan long-term care services)

7 These benchmark plans were later modified by the Children’s Health Insurance Program Reauthorization Act of 2009
(P.L. 111-3) and the Patient Protection and Affordable Care Act (P.L. 111-148, as amended).
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(i) mandatory pregnant women with income below 133% of the federal poverty level (FPL)
(viii) certain children in foster care receiving child welfare services (under Title IV-B) or certain
children for whom adoption or foster care assistance is made available (under Title IV-E), without
regard to age
(ix) Temporary Assistance for Needy Families (TANF) and Section 1931(i) parents
(x) optional breast and cervical cancer women (under age 65, with income below 250% FPL who
are identified through the Centers for Disease Control screening program who need treatment for
either of these cancers and are not eligible for other creditable coverage)
(xi) limited services beneficiaries, including optional tuberculosis-infected individuals with income up
to the level applicable to mandatory SSI populations, or individuals who are not a qualified alien
(e.g., certain aliens lawfully admitted for permanent residence in the U.S.) and for whom only
treatment of emergency medical conditions is covered (as per Section 1903(v))
Source: Section 1937(a)(2)(B) of the Social Security Act and 42 CFR 440.315.
These exempted groups may get traditional Medicaid benefits or may be offered voluntary
enrollment in benchmark benefit plans. In such cases, states must describe the differences
between traditional Medicaid and benchmark plans to these beneficiaries in order to facilitate an
informed choice.
In general, benchmark benefit packages may cover fewer benefits than traditional Medicaid, but
there are some requirements, such as coverage of EPSDT and transportation to and from medical
providers (as per a recent regulation8), that might make them more generous than private health
care insurance. The benchmark options include
• the Blue Cross/Blue Shield standard provider plan under the Federal Employees
Health Benefits Program (FEHBP),
• a plan offered to state employees,
• the largest commercial health maintenance organization (HMO) in the state, and
• other Secretary-approved coverage appropriate for the targeted population.
Benchmark-equivalent coverage must have the same actuarial value as one of the benchmark
plans identified above. Such coverage must include (1) inpatient and outpatient hospital services;
(2) physician services; (3) lab and x-ray services; (4) emergency care; (5) well-child care,
including immunizations; (6) prescribed drugs; (7) mental health services; and (8) other
appropriate preventive care (designated by the Secretary). Such coverage must also include at
least 75% of the actuarial value of coverage under the applicable benchmark plan for vision care
and hearing services (if any).
For children under age 21 in one of the major mandatory and optional Medicaid eligibility
groups, benchmark and benchmark-equivalent coverage must include EPSDT. Also, Medicaid
beneficiaries enrolled in such coverage must have access to services provided by rural health
clinics and federally qualified health centers.
Starting in 2014, both benchmark and benchmark-equivalent packages must cover at least the
essential health benefits that will also apply to plans in the private individual and small group

8 Department of Health and Human Services, Centers for Medicare and Medicaid Services, Medicaid Program: States
Flexibility for Medicaid Benefit Packages, Final Rule, 75 Federal Register, 23068 (April 30, 2010).
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Traditional Versus Benchmark Benefits Under Medicaid

health insurance markets. The 10 essential health benefits include (1) ambulatory patient services,
(2) emergency services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and
substance use disorder services (including behavioral health treatment), (6) prescribed drugs, (7)
rehabilitative and habilitative services and devices, (8) lab services, (9) preventive and wellness
services and chronic disease management, and (10) pediatric services, including oral and vision
care.9 Many of these essential health benefits are currently coverable under benchmark packages.
All benchmark plans must also cover family planning services and supplies.
Mental Health Parity Requirements Under Both Traditional
Medicaid and Benchmark Plans
The federal mental health parity requirements, as established in the Public Health Service Act
(Section 2726), generally require that, under a given insurance plan, coverage of mental health
services (if offered) should be on par with coverage of medical and surgical services in terms of
the treatment limitations (e.g., amount, duration and scope of benefits), financial requirements
(e.g., beneficiary co-payments), in- and out-of-network covered benefits, and annual and lifetime
dollar limits. Managed care plans under both traditional Medicaid and benchmark packages must
comply with all federal mental health parity requirements. Benchmark packages that are not
managed care plans are only required to comply with federal requirements for parity in treatment
limitations and financial requirements. However, these plans are deemed to comply with federal
mental health parity requirements if they offer EPSDT, which they are statutorily required to
cover.10
State Experience with Medicaid Benchmark Packages
As noted above, states have had the authority to implement benchmark benefit packages in their
Medicaid programs since the Deficit Reduction Act of 2005. A summary of state and territory
experiences with benchmark benefits as of July 2012 is provided in Table 4. Of the 12 states and
one territory (Guam) with approved benchmark plans, 11 had only one such plan and 2 (Idaho
and Kentucky) had more than one benchmark plan. The type of benchmark used in 10 states and
Guam was classified as secretary-approved, which generally means the benefit plan was tailored
to the targeted population(s) to be enrolled. Missouri had a plan classified as benchmark-
equivalent to the FEHBP Blue Cross/Blue Shield standard option preferred provider organization
(PPO). One of Kentucky’s plans was identified as benchmark-equivalent to a state employee
health plan, while Wisconsin provided coverage offered through the state’s largest health
maintenance organization (HMO), the United Health Care Choice Plus Plan. In eight states
(Connecticut, District of Columbia, Kansas, Minnesota, Missouri, Virginia, West Virginia, and
Wisconsin) and Guam, benchmark plans were available statewide. In other states (Idaho,
Kentucky, New York, and Washington), benchmark plans were limited to sub-state areas, such as
specific counties or cities.

9 See the “Essential Health Benefits Bulletin” at http://cciio.cms.gov/resources/files/Files2/12162011/
essential_health_benefits_bulletin.pdf. This document notes that CMS plans to issue further guidance on essential
health benefits implementation in the Medicaid program.
10 For more detailed information on mental health parity under Medicaid including substance use disorder services, see
CRS Report R41768, Mental Health Parity and Mandated Coverage of Mental Health and Substance Use Disorder
Services After the ACA, by Amanda K. Sarata.
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The state-level details with respect to the covered services offered through Medicaid benchmark
plans were quite varied, at least in part reflecting the populations to be enrolled in these plans and
the unique objectives of each state. Preventive and primary care services (e.g., nutrition
counseling, smoking cessation services, weight management counseling, dental care for adults)
were covered in several states. Support services designed to facilitate independent living in
community-based settings for individuals with disabilities and/or the elderly were components of
benchmark plans in a few states.
There was also considerable state-level variation in other benchmark plan characteristics. Across
the 17 state/plan combinations shown in Table 4,11 there was almost an even split between
benchmark programs for which enrollment was mandatory versus voluntary. There was also quite
a bit of variation in terms of the type of service delivery systems utilized. Fee-for-service alone (8
of 17 state/plan combinations) or in conjunction with some type of managed care arrangement (5
of 17 state/plan combinations) were the two most common service delivery system designs.
It is unclear how these state experiences to date with Medicaid benchmark plans will influence
the design of such service packages roughly two years from now in 2014 when all states will be
required to provide benchmark benefits to the new group of non-elderly, non-pregnant adults with
income up to 133% of the federal poverty level. It is likely that states with no such experience
will look to those states that have implemented benchmark packages for lessons learned in order
to make choices tailored to their given circumstances and resources.


11 For additional details about Guam’s Medicaid benchmark plan, see Table 4.
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Table 4. Selected Characteristics of Medicaid Benchmark Plans
State and
Examples of
Enrollment Mandatory
Eligibility Group(s)
Type of Benchmark
Covered Benefits
or Voluntary
Geographic Area
Delivery System
Connecticut; non-elderly,
Secretary approved
Full state plan benefits
Mandatory Statewide Fee-for-Service
(FFS)
non-pregnant adults with
under CT’s traditional
income < 133% FPL
Medicaid program
District of Columbia; non-
Secretary approved
Standard Medicaid benefit
Mandatory
Statewide
Combination FFS and
elderly, non-pregnant adults
package for adults (e.g.,
managed care
with income < 133% FPL
hospital care, MD services,
Rx drugs, mental health
care)
Guam; non-elderly, non-
Secretary approved
Full state plan benefits as
Mandatory Statewide FFS
pregnant adults with income
per Section 1905(a) of the
< 133% FPL
Social Security Act
Idaho-1; children and
Secretary approved
Standard Medicaid benefit
Mandatory, with exceptions Statewide
Primary care case
working age adults
package plus preventive
for changes in medical need
management (PCCM)
care and nutrition services
Idaho-2; individuals with
Secretary approved
Preventive care, nutritional Voluntary (i.e., right to opt Statewide PCCM
disabilities or special health
services and preventive
out and receive traditional
care needs and the elderly
health assistance plus all
Medicaid mandatory
other Medicaid covered
services)
services
Idaho-3; elderly and persons Secretary approved
All Medicaid covered
Voluntary (i.e., right to opt Select counties
Managed care (through
dually eligible for Medicaid
services
out and receive traditional
Medicare Advantage Plans)
and Medicare
Medicaid mandatory
services)
Kansas; certain working
Secretary approved
State plan benefits plus
Voluntary
Statewide
FFS with option to self
disabled populations
independent living
direct care and use the
counseling to direct and
cash and counseling model
manage needed services
(e.g., purchase services of
and budgets for that care;
certain caregivers, such as a
participants choose to self
family member, that are
direct care or have an
provided in a home setting)
agency do so
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State and
Examples of
Enrollment Mandatory
Eligibility Group(s)
Type of Benchmark
Covered Benefits
or Voluntary
Geographic Area
Delivery System
Kentucky-1; general
Secretary approved (Global All mandatory benefits plus Mandatory
Statewide (excluding 16
FFS
Medicaid population; foster
Choices)
dental care; physical,
counties near Louisville
care and medically fragile
occupational, speech
operating under an 1115
children; elderly and
therapy; non-emergency
waiver)
disabled not opting into KY-
transportation, Rx drugs,
3 and KY-4 (described
prosthetic devices
below)
Kentucky-2; families
Benchmark-equivalent to
All mandatory benefits plus Mandatory
Statewide (excluding 16
FFS
state employee health plan
chiropractic services;
counties near Louisville
(Family Choices)
speech, physical and
operating under an 1115
occupational therapy; home
waiver)
health and skilled nursing
Kentucky-3; individuals
Secretary approved
All mandatory benefits plus Voluntary
Statewide (excluding 16
FFS
needing a nursing home
(Comprehensive Choices)
vision care, chiropractic
counties near Louisville
level of care; includes such
services, dental care,
operating under an 1115
persons receiving care in
hearing and audiometric
waiver)
the community
services
Kentucky-4; individuals with Secretary approved
All mandatory benefits plus Voluntary
Statewide (excluding 16
FFS
mental retardation and
(Optimum Choices)
dental care, vision care,
counties near Louisville
developmental disabilities
chiropractic services,
operating under an 1115
who meet an ICF/MR level
hearing and audiometric
waiver)
of care
services
Minnesota; non-elderly,
Secretary approved
Alcohol/drug treatment,
Mandatory
Statewide
Combination FFS and
non-disabled, non-pregnant
chiropractic care, dental
managed care
adults otherwise ineligible
care, eyeglasses, family
for the state’s traditional
planning services, hospital
Medicaid and “prepaid
services, interpreter
medical assistance plus”
services, home health care,
programs with gross
nursing home and ICF-MR
income < 75% FPL (no
facility care, prescriptions
resource test)
Missouri; parents and
Benchmark equivalent to
Selected traditional
Mandatory
Statewide
Combination FFS and
specified caretaker relatives federal Blue Cross/Blue
mandatory and optional
managed care
up to 100% FPL—NOT
Shield Standard option
benefits plus transplant
IMPLEMENTED
preferred provider
related services
organization (PPO)
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State and
Examples of
Enrollment Mandatory
Eligibility Group(s)
Type of Benchmark
Covered Benefits
or Voluntary
Geographic Area
Delivery System
New York; categorically
Secretary approved
Traditional state plan
Voluntary Bronx
FFS
eligible adults ages 21 - 63
benefits plus medication
therapy management
Virginia; certain working
Secretary approved
Traditional state plan
Voluntary Statewide FFS
individuals with disabilities
benefits plus personal
assistance services in
various settings
Washington; Aged, blind or Secretary approved
Traditional state plan
Voluntary
King County
Pre-paid ambulatory health
disabled adults age 21+ with
benefits plus chronic care
plan and Regional Support
certain chronic, complex
management, coordination
Networks for mental
medical conditions
between behavioral health
health services
(categorically needy only)
systems and other services
(e.g., housing,
transportation)
West Virginia; TANF and
Secretary approved
Basic package—all
Mandatory
Statewide
Combination managed care
TANF-related individuals
mandatory services plus
and FFS
home health, DME,
prescribed drugs, tobacco
cessation; Enhanced
package—basic package
plus weight management,
podiatry, skilled nursing
care, mental health care
Wisconsin; pregnant
State’s largest HMO
Family planning, child health Mandatory Statewide Combination
managed
women and infants with
(United Health Care
screenings, inpatient
care, FFS, and PCCM
income between 200-250%
Choice Plus Plan)
hospital services, mental
FPL, and newborns of
health and substance abuse
women with income
services, nursing home
between 200-250% FPL
care, prescribed drugs,
smoking cessation services,
transportation
Source: Centers for Medicare & Medicaid Services, Office of Legislation, personal communication, July 26, 2012, based on information that was current as of July, 2012.
Notes: DME means durable medical equipment. ICF/MR means intermediate care facility for the mentally retarded that provides 24-hour rehabilitative and health care
services for people with developmental disabilities. TANF refers to the Temporary Assistance for Needy Families program, which provides cash assistance to certain low-
income families. PPO means preferred provider organization. Under the FFS delivery system, payments are made for each unit of service delivered. Under managed care
delivery systems, payments are made on a predetermined, per-person-per-month basis. Under PCCM delivery systems, primary care physicians are paid a small, pre-set
monthly fee per enrolled beneficiary to provide basic medical care, and serve as case managers or gate-keepers (via referrals) to specialty care (e.g., mental health care,
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dental services). A pre-paid ambulatory health plan provides less than comprehensive services on an at-risk or other than state plan reimbursement basis, and does not
provide, arrange for, or otherwise have responsibility for the provision of any inpatient hospital or institutional services. Washington State had another Secretary-approved
statewide benchmark plan similar to the plan outlined in this table in a single county. The King county-specific plan supersedes the statewide plan. Finally, New York state
withdrew its program on June 7, 2012.
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Traditional Versus Benchmark Benefits Under Medicaid

Additional CRS Medicaid and CHIP Resources
CRS Report RL33202, Medicaid: A Primer
CRS Report R41210, Medicaid and the State Children’s Health Insurance Program (CHIP)
Provisions in ACA: Summary and Timeline
CRS Report R40226, P.L. 111-3: The Children’s Health Insurance Program Reauthorization Act
of 2009

Author Contact Information

Elicia J. Herz

Specialist in Health Care Financing
eherz@crs.loc.gov, 7-1377


Congressional Research Service
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