Tracking State Medicaid Expansion Alternative Benefit Plans
*Chart updated December 31, 2014
States that choose to expand Medicaid have the flexibility to determine what benefits they will offer to the newly eligible population. The set of benefits offered to the new adult group (all non-elderly, non-pregnant adults with incomes at or below 138 percent FPL) is known as an Alternative Benefit Plan (ABP). This chart tracks the status of state ABP decisions for the Medicaid expansion population. We include draft or preliminary materials on ABPs when a state has not yet submitted or received approval from CMS (where available).
Benefits in a state’s ABP can differ from those offered in traditional Medicaid, but they must be benchmarked to particular plans in the state and must cover all ten required Essential Health Benefits (EHBs).1 ABPs must also comply with mental health parity and include non-emergency transportation, prescription drugs, and family planning benefits. In addition, for children and youth under age 21, states must ensure Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services are included.2 States can choose different ABPs for different groups of newly eligible individuals, or use the same plan for multiple groups. States are also able to use their traditional Medicaid benefits package as their ABP, as long as it provides coverage of required services.
Like all State Refor(u)m research, this chart is a collaborative effort with you, the user. State Refor(u)m captures the health reform comments, documents, and links submitted by health policy thinkers and doers all over the country. And our team periodically supplements, analyzes, and compiles this key content.
Know of something we should add to this compilation? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment below, or email the author (ksheedy@oldsite.nashp.org) with your suggestion.
| State | Type of Expansion | ABP Status | Benefit Package for the Newly Eligible Population | ABP Coverage Option | Essential Health Benefit (EHB) Benchmark Plan | ABP Notes |
|---|---|---|---|---|---|---|
| Traditional expansion: State is implementing Medicaid expansion as outlined in the ACA Non-traditional expansion: State is using an 1115 demonstration waiver to expand Medicaid Not expanding: State is not expanding Medicaid at this time |
Information about where the state is in the process of submitting and having its ABP State Plan Amendment (SPA) approved by CMS | State decision on benefit package for the population receiving an ABP; includes name of Medicaid ABP | State must select a coverage option from the choices found in Section 1937 of the Social Security Act [3] | The state must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark Equivalent Package[4]; includes plan name | Details about state ABP decision-making process | |
| AL | Not expanding | |||||
| AK | Not expanding | |||||
| AZ | Traditional expansion | Approved SPA | AHCCCS ABP: The newly eligible population will receive the set of Medicaid benefits provided to the state’s categorically eligible population to help minimize disruptions for individuals who move among different eligibility categories within the AHCCCS program. | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Any of the largest three state employee health benefit plans by enrollment:United Health Care EPO | Currently utilizes an inpatient hospital limitation of 25 days per year for the new adult group and other Arizona Medicaid beneficiaries; limitation will be removed on October 1, 2014 |
| AR | Non-traditional expansion | |||||
| CA | Traditional expansion | Approved SPA | ABP Adult Group | Secretary-approved coverage based on benefits provided in approved state plan | Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment: Blue Cross Blue Shield FEHBP | |
| CO | Traditional expansion | Approved SPA | Alternative Benefit Plan: CO will use the same base benchmark for the ABP that the CO Marketplace is using for Qualified Health Plans to help ease transitions as individuals churn across public and private coverage. CO will offer traditional Medicaid state plan Medicaid benefits to the expansion population to ease transition of clients who churn across 1937 and 1905(a) coverage; ABP will offer all remaining preventive services not currently offered in Medicaid state plan and habilitative services | Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages | Any of the largest three state employee health benefit plans by enrollment:Kaiser Foundation Health Plan of Colorado Ded HMO 1200D | |
| CT | Traditional expansion | Approved SPA | ABP for Medicaid Coverage for the Lowest-Income Populations (MCLIP): Fully aligned benefits in ABP with approved Medicaid State Plan and using duplication and substitution for the EHB benefits in base benchmark plan; including remaining medicaid state plan services as other 1937 covered benefits that are not EHBs | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment: Blue Cross Blue Shield Service Benefit Plan-Basic Option | |
| DC | Traditional expansion | Approved SPA | Alternative Benefit Plan: Benefits are identical to the Medicaid State Plan covering all ten EHBs in an amount and scope that is equal to or greater than those provided in the base-benchmark plan selected by the District. | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: BCBS/Carefirst Blue Preferred Option 1 | |
| DE | Traditional expansion | Public notice of intent to file SPA with CMS | ||||
| FL | Not expanding | |||||
| GA | Not expanding | |||||
| HI | Traditional expansion | Approved SPA | Hawaii Alternative Benefits Health Plan: Benefits in ABP are the same as offered in the Hawaii Medicaid state plan with the following exception: habilitative services are provided through Medicaid 1115(a)(2) waiver authority as costs not otherwise matchable. | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Hawaii Medical Service Association Preferred Provider Plan 2010 | |
| ID | Not expanding | |||||
| IL | Traditional expansion | Approved SPA | ACA Adult Group: State compared services covered by its Medicaid state plan with the services covered by its selected base benchmark plan; services covered by base benchmark but not the Medicaid state plan were excluded from the ABP through the appropriate substitution process | Secretary-approved coverage based on benefits provided in approved state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Blue Cross Blue Shied BlueAdvantage Entrepreneur | |
| IN | Proposed non-traditional expansion | |||||
| IA | Non-traditional expansion | 2 Approved SPAs: Iowa Wellness Plan [5] Iowa Marketplace Choice Plan [6] |
Iowa Wellness Plan: A combination of benefits that include: the state employee coverage offered and generally available to state employees and the Medicaid State Plan including the prescription drug benefit and urgent dental services; urgent dental services provided through existing Medicaid provider network and will include medically necessary emergent and stabilization dental services including services treating infection, acute pain, or trauma and related diagnostic services Iowa Marketplace Choice Plan: benefits from the base benchmark plan offered in the Marketplace which is the largest small group plan in IA’s small group market plus dental coverage from the Medicaid State Plan; will also provide medically necessary emergent and stabilization dental services including services treating infection, acute pain, or trauma and related diagnostic services through existing Medicaid provider network |
Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages (both Iowa Wellness Plan and iowa Marketplace Choice) | Any of the largest three state employee health benefit plans by enrollmet: Wellmark Inc Blue Access (Iowa Wellness Plan) Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Wellmark Inc. Alliance Select, Copayment Plus (Iowa Marketplace Choice Plan) |
|
| KS | Not expanding | |||||
| KY | Traditional expansion | Approved SPA | KY Health Choices | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Anthem Blue Cross Blue Shield Small Group PPO | |
| LA | Not expanding | |||||
| ME | Not expanding | |||||
| MD | Traditional expansion | Approved SPA | State Plan Adult Benefit: Benefits in ABP align with Medicaid state plan; newly eligible will also receive habilitative services | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: CareFirst Small Group Plan | |
| MA | Traditional expansion | Two Approved SPAs: MassHealth Standard [7] MassHealth CarePlus [8] |
MassHealth Standard: Benefits in the MassHealth Standard ABP are the same as offered in the Massachusetts Medicaid State Plan. MassHealth CarePlus: Benefits in the MassHealth CarePlus ABP are the same as offered in the Massachusetts Medicaid State Plan with the following exceptions: benefits targeted for individuals under 21 years of age, including EPSDT are not included because CarePlus eligibility will be limited to individuals 21 years of age or older; Long term services and supports are generally not available in the CarePlus ABP (including ambulatory patient services; skilled nursing visits as part of home health; limited part-time nursing services benefits; no nursing facility services for individuals 21 or older; no adult day health, adult foster care, group adult foster care, or day habilitation services; no personal care, intermediate care facility or private duty nursing services) |
MassHealth Standard: Secretary-approved coverage based on benefits provided in approved Medicaid state plan MassHealth CarePlus: Secretary-approved coverage based on benefits provided in approved Medicaid state plan; state offers only a partial list of benefits provided in the approved state plan |
Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment: 2012 Government Employees Health Association, Inc. (for both MassHealth Standard and MassHealth CarePlus) | |
| MI | Non-traditional expansion | Approved SPA | Healthy Michigan Plan | Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Priority Health HMO | |
| MN | Traditional expansion | Approved SPA | Group VIII Adults | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Health Partners 500 25 Open Access | |
| MS | Not expanding | |||||
| MO | Not expanding | |||||
| MT | Not expanding | |||||
| NE | Not expanding | |||||
| NV | Traditional expansion | Approved SPA | Nevada Medicaid Newly Eligible Benefit: Adding Habilitation- Maintenance Therapy as the EHB for both newly eligibles and existing Medicaid State Plan. The Medicaid State Plan will be modified to align the existing State Medicaid Plan and the Alternative Benefit Plan. | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment: Federal Employees Health Benefit Plan BCBS Basic/Standard Option 2012 Benefit Plan | |
| NH | Non-traditional expansion | Approved SPA | Adult Group Alternative Benefit Package: Benefit package based on the base benchmark plan selected by the state to define EHBs for products in the marketplace; state has added additional benefits required for the ABP, such as non-emergency medical transportation, EPSDT, routine eye exams, eyeglasses, and dental; individuals will also have access to FQHC and RHC services as well as open access to family planning providers | Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Matthew Thornton Blue Health Plan | |
| NJ | Traditional expansion | Approved SPA | NJ FamilyCare ABP: The newly eligible population will receive the state plan Medicaid package excluding MLTSS and including additional mental health and substance abuse services; except for those in exemption based on a special health care need, who have the option of selecting the Medicaid State Plan package or the ABP | Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages | Largest insured commercial non-Medicaid HMO: Horizon HMO | |
| NM | Traditional expansion | Approved SPA | Expansion Alternative Benefit Plan | Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Lovelace Classic PPO | |
| NY | Traditional expansion | Draft SPA | Adult Group Benefit: The state first chose the Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program as the benchmark plan and compared it to the Essential Health Benefits and to the Medicaid State Plan. The Medicaid State Plan covers all the benefits in the benchmark plan except chiropractic services. The state is proposing to substitute personal care services from the Medicaid State Plan for this benchmark covered benefit. In addition to EHBs, the ABP includes the 1937 covered benefits in the Medicaid State Plan. | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment: Standard Blue Cross Blue Shield Federal Employee | |
| NC | Not expanding | |||||
| ND | Traditional expansion | Testimony indicating that the Sanford Health Plan, plus EHBs and required Medicaid services, would be the state’s ABP | ||||
| OH | Traditional expansion | Approved SPA | ABP for Childless Adults up to 133% FPL: benefits in the ABP are the same as offered in Medicaid state plan with the following exceptions: quantitative limitations that were applied to Mental Health outpatient services, AOD Intensive outpatient services, and psychologist services in the Ohio Medicaid state plan have been eliminated in the ABP; mental health and substance use disorders including behavioral health treatment are in ABP | Secretary-approved coverage: benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Anthem Blue Access PPO | |
| OK | Not expanding | |||||
| OR | Traditional expansion | Approved SPA | Oregon Health Plan: Full set of Medicaid benefits provided to the state’s categorically eligible population to help minimize disruptions for individuals who move among different benefit packages within The Oregon Health Plan. Benefits in the ABP that are determined essential health benefits are consistent with the amount, duration and scope of the prioritized list and must equal or exceed each of the base benchmark benefits duplicated groupings, which define the floor of coverage for an ABP. Benefits in the ABP that are determined to be other 1937 covered benefits that are not essential health benefits provided through the state plan may be limited by the prioritized list in the same manner as other populations in the waiver. | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: PacificSource Preferred CoDeduct Value 3000 35 70 | |
| PA | Non-traditional expansion | |||||
| RI | Traditional expansion | Approved SPA | Rhode Island Benefit Plan: Benefits correspond to existing Rhody Health Partners package of Medicaid State Plan benefits | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Blue Cross Blue Shield of RI Vantage Blue Plan | |
| SC | Not expanding | |||||
| SD | Not expanding | |||||
| TN | Not expanding | |||||
| TX | Not expanding | |||||
| UT | Not expanding | |||||
| VT | Traditional expansion | Approved SPA | Medicaid State Plan | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market:BlueCare, Vermont Health Plan, LLC, CDHP HMO | |
| VA | Not expanding | |||||
| WA | Traditional expansion | Approved SPA | Alternative Benefit Plan 1: Benefits correspond to Medicaid State Plan, but habilitation services beyond those found in the Medicaid State Plan are provided in this ABP. (A SPA is being submitted to revise the scope of Medicaid state plan services to include preventive services, mental health parity, and provide other benefits authorized by the state legislature, including dental coverage and naturopathic services.) | Secretary-approved coverage based on benefits provided in approved Medicaid state plan | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Regence Innova | |
| WV | Traditional expansion | Approved SPA | WV Health Bridge Plan: The ABP benefit package cloesly mirrors the WV Medicaid State Plan coverage; any difference or limitations are noted in ABP | Secretary-approved coverage: the state offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, or the approved Medicaid state plan or from a combination of these benefit packages | Largest plan by enrollment of the three largest small group insurance products in the state’s small group market: Highmark Blue Cross Blue Shield West Virginia | |
| WI | Not expanding | |||||
| WY | Not expanding | |||||
Download PDF
Notes:
[1] Section 2001(c) of the Affordable Care Act modifies the benefit provisions of section 1937 of the Social Security Act, which was established by the Deficit Reduction Act of 2005, by adding mental health benefits and prescription drug coverage to the list of benefits that must be included in benchmark-equivalent coverage; requiring Essential Health Benefits (EHBs) beginning in 2014; and directing that section 1937 benefit plans that include medical/surgical benefits and mental health and/or substance use disorder benefits comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
[2] The Medicaid EPSDT benefits include all medically necessary services regardless of whether they are in the Medicaid State Plan.
[2] The Medicaid EPSDT benefits include all medically necessary services regardless of whether they are in the Medicaid State Plan.
[3] Four options that States should choose from for the Medicaid ABP:
- The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employees Health Benefit program.
- State employee coverage that is offered and generally available to state employees.
- Commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state.
- Secretary-approved coverage, a benefit package the Secretary has determined to provide coverage appropriate to meet the needs of the population.
[5] Enrollment is mandatory for people with income from 0 to 100% FPL without access to cost-effective employer sponsored insurance (ESI) and do not have an exempt individual status as defined by 42 CFR sec.440.315. People with access to cost-effective ESI will be enrolled in their ESI as the primary payer. Eligible services not provided by the member’s ESI plan will be covered by the Iowa Wellness Plan. People with income up to 133% of the FPL who have an exempt status will be enrolled in the ABP that is the Medicaid State Plan and have an option to enroll in the Iowa Wellness Plan ABP.
[6] Enrollment in the Iowa Marketplace Choice Plan will be mandatory for those persons who have income from 101 to 133% of the Federal Poverty Level (FPL) so long as they do not have access to cost-effective employer sponsored insurance (ESI) and do not have an exempt individual status as defined by 42 CFR sec.440.315. Persons who have access to cost-effective ESI will be enrolled in their ESI as the primary payer. Any eligible services not provided by the member’s employer sponsored plan will be covered under the Iowa Wellness Plan. Persons with income up to 133% of the FPL who have an exempt individual status will be initially enrolled in the Medicaid State Plan but will be notified of their option of receiving benefits in the Iowa Wellness Plan.
[7] The MassHealth Standard ABP is provided to all 19-20 year olds eligible under the new adult group, individuals ages 21-64 who met the targeting criteria above or who are receiving services from the Massachusetts Department of Mental Health or who are on a waiting list to receive such services.
[8] The MassHealth CarePlub ABP is provided to all 21-64 year olds solely eligible under the new adult group, other than those described as one of the targeted populations identified in MassHealth Standard ABP.
Chart produced by Kaitlin Sheedy
Related categories:
– See more at: https://www.statereforum.org/Tracking-State-Medicaid-Alternative-Benefit-Plans#sthash.0LJBDGOx.dpuf
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
