The Medicaid program, which served 72 million people in FY2012, 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 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.
The Medicaid program, which served 72 million people in FY2012, 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 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.
Medicaid was established in 1965 to provide basic medical services to certain low-income populations. It is a means-tested entitlement program that financed the delivery of primary and acute medical services, as well as long-term services and supports, to more than an estimated 72 million people in FY2012.1 The estimated annual cost to the federal and state governments for Medicaid was roughly $432 billion in FY2011.2
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 late 2012. Additional CRS resources on the Medicaid and Children's Health Insurance Program are provided at the end of this report.
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.
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 with income 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.
|
Type of Benefit and Benefit Package |
Eligibility Classification: |
|||
|
Categorically Needy (excluding Non-Elderly, Non-Pregnant Adults) |
Medically Needy |
Section 1115 Waivers |
Non-Elderly, Non-Pregnant Adults |
|
|
Mandatory |
-Inpatient hospital -Nursing facility care (age 21+) -EPSDT (< age 21) -Physicians -Federally-qualified health centers -Family planning -Pregnancy-related services |
-Prenatal and delivery services -Ambulatory services (< age 18; persons entitled to institutional care) -Home health for those entitled to nursing facility care |
-Negotiated between the states and the Secretary of Health and Human Services (HHS) |
-Benchmark plans |
|
Optional |
-Clinic services -Prescribed drugs -Physical, occupational, and speech therapy -Other practitioners -Dental |
-Nursing facility care -Clinic services -Physical, occupational, and speech therapy -Other practitioners -Dental |
-Negotiated between the states and Secretary of HHS |
-For special needs subgroups, option to have same benefits as categorically needy or enroll in benchmark plan |
|
Traditional Benefits Versus Benchmark Package |
Traditional Benefits |
Traditional Benefits |
Not applicable |
Benchmark plans with exceptions; see 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.
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.
Table 2. Examples of Frequently Covered Optional Benefits Under Traditional Medicaid as of December 2010/January 2011
|
Selected Optional Benefits |
Number of States Offering Benefit |
Description of Benefit |
|
Examples of Preventive, Primary, and Acute Care Services |
||
|
Clinic Services |
49 |
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 (three states restrict such care to individuals under age 21) |
|
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 Therapy |
49 |
Services to diagnose and treat speech and language problems (three states restrict such care to individuals under age 21) |
|
Targeted Case Management |
50 |
Services to help individuals be independent and learn to manage their health care, including linking such people with health care providers, social services, educational services, etc., based on that person's needs (one state restricts such care to individuals under age 21) |
|
Examples of Long-Term Services and Supports |
||
|
Inpatient Psychiatric Services for Individuals < Age 21 |
48 |
Services that a person < age 21 might receive at a hospital or psychiatric residential treatment facility while staying overnight for treatment of mental illness, and may include services provided by a physician or nurse, lab work, surgery, and drugs |
|
Intermediate Care Facilities for the Mentally Retarded |
51 |
Services at a facility that provides 24-hour rehabilitative as well as health care and services for persons with developmental disabilities (one state restricts such care to individuals under age 21) |
|
Nursing Facility Services for Individuals < Age 21 |
50 |
Skilled nursing, rehabilitation, and other services provided in 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 |
|
Personal Care Services |
35 |
Services that help individuals with chronic or temporary conditions to remain in their homes by helping them with activities of daily living (e.g., bathing, dressing, grocery shopping); such services can be delivered by agencies or individual providers or can be directed by patients or their families |
|
Targeted Case Management for Mental Health |
51 |
Services to help individuals with mental health needs learn how to manage their health care |
Source: Centers for Medicare & Medicaid Services, derived from http://www.healthcare.gov and individual state Medicaid websites as of December 2010 and January 2011, personal communication, winter of 2011.
Note: The definition of state includes the District of Columbia.
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.
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 eligibility for 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) |
|
(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 2010 regulation8), that might make them more generous than private health care insurance. The benchmark options include
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 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.
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
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 December 2012 is provided in Table 4. Of the 12 states and one territory (Guam) with approved benchmark plans, 10 had only one such plan and 3 (Idaho, Kentucky, and Wisconsin) 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. Wisconsin provided coverage offered through the state's largest health maintenance organization (HMO), the United Health Care Choice Plus Plan, for pregnant women, newborns and infants. In selected counties, this state also provided Medicaid state plan services to certain foster care children using both managed care and a medical home arrangement. 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.
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 18 state/plan combinations shown in Table 4,11 there was 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 18 state/plan combinations) or in conjunction with some type of managed care arrangement (6 of 18 state/plan combinations) were the two most common service delivery system designs.
It is unclear how these state experiences with Medicaid benchmark plans to date will influence the design of such benefit packages in 2014 among states that choose to cover the new optional 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.
|
State and Eligibility Group(s) |
Type of Benchmark |
Examples of Covered Benefits |
Enrollment Mandatory or Voluntary |
Geographic Area |
Delivery System |
|
Connecticut; non-elderly, non-pregnant adults with income < 133% FPL |
Secretary approved |
Full state plan benefits under CT's traditional Medicaid program |
Mandatory |
Statewide |
Fee-for-Service (FFS) |
|
District of Columbia; non-elderly, non-pregnant adults with income < 133% FPL |
Secretary approved |
Standard Medicaid benefit package for adults (e.g., hospital care, MD services, Rx drugs, mental health care) |
Mandatory |
Statewide |
Combination FFS and managed care |
|
Guam; non-elderly, non-pregnant adults with income < 133% FPL |
Secretary approved |
Full state plan benefits as per Section 1905(a) of the Social Security Act |
Mandatory |
Statewide |
FFS |
|
Idaho-1; children and working age adults |
Secretary approved |
Most standard Medicaid benefits plus preventive care and nutrition services |
Mandatory, with exceptions for changes in medical need |
Statewide |
Primary care case management (PCCM) |
|
Idaho-2; individuals with disabilities or special health care needs and the elderly |
Secretary approved |
Preventive care, nutritional services, LTC and extended mental health services plus all other Medicaid benchmark benefits |
Voluntary (i.e., right to opt out at any time and receive traditional Medicaid mandatory services) |
Statewide |
PCCM |
|
Idaho-3; elderly and persons dually eligible for Medicaid and Medicare |
Secretary approved |
All Medicaid covered services (and Medicare Advantage benefits) |
Voluntary (i.e., right to opt out and receive traditional Medicaid mandatory services) |
Select counties |
Managed care (through Medicare Advantage Plans) |
|
Kansas; certain working disabled populations |
Secretary approved |
State plan benefits plus independent living counseling to direct and manage needed services and budgets for that care; participants choose to self direct care or have an agency do so |
Voluntary |
Statewide |
FFS with option to self direct care and use the cash and counseling model (e.g., purchase services of certain caregivers, such as a family member, that are provided in a home setting) |
|
Kentucky-1; general Medicaid population; foster care and medically fragile children; elderly and disabled not opting into KY-3 and KY-4 (described below) |
Secretary approved (Global Choices) |
All mandatory benefits plus dental care; physical and speech therapy; non-emergency transportation, Rx drugs, prosthetic devices |
Mandatory |
Statewide (excluding 16 counties near Louisville operating under an 1115 waiver) |
FFS |
|
Kentucky-2; families |
Benchmark-equivalent to state employee health plan (Family Choices) |
All mandatory benefits plus chiropractic services; speech, physical and occupational therapy; home health and skilled nursing |
Mandatory |
Statewide (excluding 16 counties near Louisville operating under an 1115 waiver) |
FFS |
|
Kentucky-3; individuals needing a nursing home level of care; includes such persons receiving care in the community |
Secretary approved (Comprehensive Choices) |
All mandatory benefits plus vision care, chiropractic services, dental care, hearing and audiometric services |
Voluntary |
Statewide (excluding 16 counties near Louisville operating under an 1115 waiver) |
FFS |
|
Kentucky-4; individuals with mental retardation and developmental disabilities who meet an ICF/MR level of care |
Secretary approved (Optimum Choices) |
All mandatory benefits plus dental care, vision care, chiropractic services, hearing and audiometric services |
Voluntary |
Statewide (excluding 16 counties near Louisville operating under an 1115 waiver) |
FFS |
|
Minnesota; non-elderly, non-disabled, non-pregnant adults otherwise ineligible for the state's traditional Medicaid and "prepaid medical assistance plus" programs with gross income < 75% FPL (no resource test) |
Secretary approved |
Alcohol/drug treatment, chiropractic care, dental care, eyeglasses, family planning services, hospital services, interpreter services, home health care, nursing home and ICF-MR facility care, prescriptions |
Mandatory |
Statewide |
Combination FFS and managed care |
|
Missouri; parents and specified caretaker relatives up to 100% FPL—NOT IMPLEMENTED |
Benchmark equivalent to federal Blue Cross/Blue Shield Standard option preferred provider organization (PPO) |
Selected traditional mandatory and optional Medicaid benefits |
Mandatory |
Statewide |
Combination FFS and managed care |
|
New York; categorically eligible adults ages 21 - 63 |
Secretary approved |
Traditional state plan benefits plus medication therapy management |
Voluntary |
Bronx |
FFS |
|
Virginia; certain working individuals with disabilities |
Secretary approved |
Traditional state plan benefits plus personal assistance services in various settings |
Voluntary |
Statewide |
FFS |
|
Washington; Aged, blind or disabled adults age 21+ with certain chronic, complex medical conditions (categorically needy only) |
Secretary approved |
Traditional state plan benefits plus chronic care management, coordination between behavioral health systems and other services (e.g., housing, transportation) |
Voluntary |
King County |
Pre-paid ambulatory health plan and Regional Support Networks for mental health services |
|
West Virginia; TANF and TANF-related individuals |
Secretary approved |
Basic package—all mandatory services plus home health, DME, prescribed drugs, tobacco cessation; Enhanced package—basic package plus weight management, podiatry, skilled nursing care, mental health care |
Mandatory |
Statewide |
Combination managed care and FFS |
|
Wisconsin-1; pregnant women and infants with income between 200-250% FPL, and newborns of women with income between 200-250% FPL |
State's largest HMO (United Health Care Choice Plus Plan) |
Family planning, child health screenings, inpatient hospital services, mental health and substance abuse services, nursing home care, prescribed drugs, smoking cessation services, transportation |
Mandatory |
Statewide |
Combination managed care, FFS, and PCCM |
|
Wisconsin-2; All non-Title IV-E foster children < age 21 (excluding those in a secure facility or residential treatment center) |
Secretary approved |
All state plan services plus dental care, immunizations, and behavioral health care |
Voluntary |
Southeast Wisconsin (selected counties) |
Combination managed care and FFS through a Prepaid Inpatient Health Plan for Foster Care Medicaid Home |
Source: Centers for Medicare & Medicaid Services, Office of Legislation, personal communication, December 5, 2012, based on information that was current as of December, 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, 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.
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
CRS Report R41600, Home and Community-Based Services Under Medicaid
| 1. |
Beneficiary statistics for FY2012 were taken from Table 1.16, 2012 CMS Statistics, U.S. Department of Health and Human Services. |
| 2. |
Expenditure statistics for FY2011 were taken from Table III.2, 2012 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 2013, the FPL for a family of four is $23,550—133% of FPL for such a family would equal $31,321.50. See http://www.gpo.gov/fdsys/pkg/FR-2013-01-24/pdf/2013-01422.pdf. |
| 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 [author name scrubbed] and [author name scrubbed]. 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. |
| 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. |
| 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). |
| 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). |
| 9. |
For more information, see the State Medicaid Directors Letter (SMDL # 12-003 dated November 20, 2012) for additional information on essential health benefits 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 [author name scrubbed]. |
| 11. |
For additional details about Guam's Medicaid benchmark plan, see Table 4. |