Readers Guide to Sample Health Care Benefits Packages

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Federal Policy Brief | May 6, 2011

Files: PDF | 126 KB | 6 pages

Under the Affordable Care Act (ACA), starting on January 1, 2014, Medicaid eligibility will expand to include all individuals under 133% of the federal poverty. Most newly eligible individuals will be covered under “benchmark plans.” These ACA benefits packages have not been fully developed by federal regulations and state legislation. Therefore, their extent and scope in any given state are not known in detail. However, previous regulatory treatment of benchmark plans may provide some insight as to how ACA benchmark plans might be implemented.

Under earlier Medicaid reforms, Congress authorized states to develop benchmark plans in which to enroll certain groups of Medicaid-eligible individuals. Few states opted to create benchmark plans. Nonetheless, current law provides for benchmark plans – benefits packages – offering medical coverage that is less comprehensive than full Medicaid benefits, easing a state’s financial burden with respect to covering less medically needy individuals.

Implementing this pre-ACA reform, Medicaid made clear in regulations that even if a state adopts benchmark plans, certain populations would be “exempt” from benchmark plans. Exempt populations include individuals with “serious emotional disturbances, disabling mental disorders, and physical and/or mental disabilities that prevent them from performing one or more tasks of daily living.” States are responsible for specifying how individuals will be identified to fall into these categories.

States may offer benchmark coverage to this population so long as they are able to clearly compare the benefits of both standard and benchmark plans. Depending on need, it might be more beneficial for an exempt individual to enroll in a benchmark plan, for instance, if her state’s usual Medicaid benefits do not cover mental health services. This is because benchmark plans must provide mental health services in parity to medical and surgical services. On the other hand, it might be less beneficial the individual needs community-based services like psychiatric rehabilitation, since benchmark plans would likely not include these benefits.

For an initial understanding of what this might mean for at-risk adults, the Alliance looked at the specific statutory language and created a chart to show possible variations in coverage, and to note commonly-used terms in health care benefits packages. That chart can be found in the full PDF of the brief, which can be accessed on this page.