[Federal Register Volume 75, Number 83 (Friday, April 30, 2010)]
[Rules and Regulations]
[Pages 23068-23104]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-9734]
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Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 440
Medicaid Program; State Flexibility for Medicaid Benefit Packages;
Final Rule
Federal Register / Vol. 75 , No. 83 / Friday, April 30, 2010 / Rules
and Regulations
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 440
[CMS-2232-F4]
RIN 0938-AP72
Medicaid Program; State Flexibility for Medicaid Benefit Packages
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This rule revises the final rule published on December 3, 2008
to implement provisions of section 6044 of the Deficit Reduction Act of
2005, which amends the Social Security Act by adding a new section 1937
related to the coverage of medical assistance under approved State
plans. That rule provides States increased flexibility under an
approved State plan to define the scope of covered medical assistance
by offering coverage of benchmark or benchmark-equivalent benefit
packages to certain Medicaid-eligible individuals. In addition, this
final rule responds to public comments on the February 22, 2008
proposed rule and comments received in response to rules published
subsequently that delayed the effective date of the December 3, 2008
final rule until July 1, 2010.
DATES: Effective Date: These regulations are effective on July 1, 2010.
FOR FURTHER INFORMATION CONTACT: Fran Crystal, (410) 786-1195.
SUPPLEMENTARY INFORMATION:
I. Background
A. Regulatory History
On December 3, 2008, we published a final rule in the Federal
Register entitled ``Medicaid Program; State Flexibility for Medicaid
Benefit Packages'' (73 FR 73694), hereafter referred to as the December
3, 2008 rule. The December 2008 rule was to implement provisions of
section 6044 of the Deficit Reduction Act (DRA) of 2005, (Pub. L. 109-
171), enacted on February 8, 2006, which amends the Social Security Act
(the Act) by adding a new section 1937 related to the coverage of
medical assistance under approved State plans.
Subsequent to the publication of the December 3, 2008 rule, and in
accordance with the memorandum of January 20, 2009 from the Assistant
to the President and the Chief of Staff, entitled ``Regulatory
Review,'' we published an interim final rule with comment period (74 FR
5808) on February 2, 2009 in the Federal Register to temporarily delay
for 60 days the effective date of the December 3, 2008 rule entitled,
``Medicaid Program; State Flexibility for Medicaid Benefit Packages.''
The February 2, 2009 interim final rule also reopened the comment
period on the policies set out in the December 3, 2008 rule. We
received nine timely items of correspondence in response to the
February 2, 2009 interim final rule.
On April 3, 2009, we published a second interim final rule (74 FR
15221) in the Federal Register effectively delaying implementation of
the December 3, 2008 rule until December 31, 2009. The second interim
final rule was published in order to allow time to incorporate
provisions of the Children's Health Insurance Program Reauthorization
Act (CHIPRA) of 2009 (Pub. L. 111-3) enacted on February 4, 2009, which
corrected language in the DRA as if these amendments were included in
the DRA, and subsequently amended section 1937 of the Act ``State
Flexibility for Medicaid Benefit Packages''. This delay also allowed
for sufficient time to fully consider all of the public comments
received on this regulation. In response to the April 3, 2009 interim
final rule with a 30-day comment period, we received seven timely items
of correspondence.
Upon further review and consideration of the new provisions of the
American Recovery and Reinvestment Act (ARRA) of 2009 (Pub. L. 111-5),
enacted on February 17, 2009), CHIPRA, and the public comments received
during the reopened comment period, we believed it necessary to revise
a substantial portion of the December 3, 2008 rule. Therefore, on
October 30, 2009, we published a proposed rule in the Federal Register
(74 FR 56151) to solicit public comments on further delaying the
effective date of the December 3, 2008 rule until July 1, 2010. We
proposed to further delay the effective date of the December 3, 2008
rule from December 31, 2009 to July 1, 2010 to allow us sufficient time
to revise a substantial portion of the final rule based on our review
and consideration of the new provisions of CHIPRA, ARRA, and the public
comments received during the reopened comment periods. To allow time to
make these revisions, the Department determined that several more
months were needed to fully consider necessary changes to the rule.
In the proposed rule, we noted that the comments received during
the reopened comment periods were complex and presented numerous policy
issues which require extensive consultation, review and analysis.
Additionally, because both CHIPRA and ARRA contain provisions that
impact the American Indian and Alaska Native community, we stated that
the development of the final rule required collaboration with other HHS
agencies and the Tribal governments. We believed that this time period
would allow sufficient time to further consider public comments,
analyze the impact of the revisions on affected stakeholders, and
develop appropriate revisions to the regulation.
We received one timely item of correspondence in response to the
October 30, 2009 proposed rule. The comment did not directly address
our proposal to delay the effective date of the December 3, 2008 rule
until July 1, 2010. The comment was limited to the exemption of the
benchmark and bench-mark equivalent packages from the assurance of
transportation requirements. Because the comment was outside the scope
of the proposed rule on the delay of the effective date of the December
3, 2008 rule, but instead addresses the issue of revisions that are
needed to comply with statutory changes, we have addressed the comment
in the revisions to the final rule.
On November 30, 2009, we published a final rule in the Federal
Register (74 FR 62501) delaying the effective date of the December 3,
2008 final rule until July 1, 2010.
B. General Provisions
Under title XIX of the Act, the Secretary is authorized to provide
funds to assist States in furnishing medical assistance to needy
individuals, whose income and resources are insufficient to meet the
costs of necessary medical services, including families with dependent
children and individuals who are aged, blind, or disabled. To be
eligible for funds under this program, States must submit a State plan,
which must be approved by the Secretary. Programs under title XIX are
jointly financed by Federal and State governments. Within broad Federal
guidelines, each State determines the design of its program, eligible
groups, benefit packages, payment levels for coverage and
administrative and operating procedures.
Before the passage of the DRA, States were required to offer at
minimum a standard benefit package to eligible populations identified
in section 1902(a)(10)(A) of the Act (with some specific exceptions,
for example, for certain pregnant women, who could be
[[Page 23069]]
limited to pregnancy-related services). Under section 1902(a)(10)(A) of
the Act, this standard benefit package had to include certain specific
benefits identified in the definition of ``medical assistance'' at
section 1905(a) of the Act. These identified benefits include inpatient
and outpatient hospital services, physician services, medical and
surgical services furnished by a dentist, rural health clinic services,
federally qualified health center services, laboratory and X-ray
services, nursing facility services, early and periodic screening,
diagnostic and treatment (EPSDT)services for individuals under age 21,
family planning services and supplies to individuals of child-bearing
age, nurse-midwife services, certified pediatric nurse practitioner,
and certified family nurse practitioner services. Under section
1902(a)(10)(D) of the Act, the standard benefit package is also
required to include home health services.
Section 6044 of the DRA amended the Act by adding a new section
1937 that allows States to amend their Medicaid State plans to provide
for the use of benefit packages other than the standard benefit
package, namely benchmark benefit packages or benchmark-equivalent
packages, for certain populations. The statute delineates what benefit
packages qualify as benchmark packages and what would constitute a
benchmark-equivalent package. The statute also specifies those exempt
populations that may not be required to enroll in a benchmark coverage
plan. To be eligible for funds under this new provision, States must
submit a State plan amendment, which must be approved by the Secretary.
On March 31, 2006, we issued a State Medicaid Director letter providing
guidance on the implementation of section 6044 of the DRA.
C. CHIPRA Technical Corrections
On February 4, 2009, CHIPRA was enacted. Section 611 of CHIPRA made
technical corrections to the Benchmark Benefit provisions in section
1937 of the Act, which were originally established under the DRA. The
CHIPRA technical correction changes take effect as if included in the
DRA.
Section 611(a)(1)(C) and section 611(a)(3) of CHIPRA require States
to assure that children under the age of 21, rather than those under 19
as originally specified in the DRA, who are included in benchmark or
benchmark-equivalent plans, have access to full EPSDT services (that
is, those found in sections 1905(a)(4)(B), 1905(r), and 1902(a)(43) of
the Act). These EPSDT services may be provided through a benchmark or
benchmark-equivalent plan and/or as an additional benefit to those
plans under section 1937 of the Act.
Section 611(a)(1)(A)(i) of CHIPRA changed the ``Notwithstanding any
other provision of this title * * *'' language in section 1937(a)(1)(A)
of the Act to ``Notwithstanding section 1902(a)(1) (relating to
statewideness), section 1902(a)(10)(B) (relating to comparability) and
any other provision of this title which would be directly contrary to
the authority under this section and subject to [subparagraph] (E)''.
One effect of this CHIPRA change is to clarify the requirement, under
42 CFR 431.53 and section 1902(a)(4) of the Act, to assure
transportation for Medicaid beneficiaries in order for them to have
access to covered State plan services is applicable, regardless of
whether beneficiaries are or are not enrolled in benchmark or
benchmark-equivalent plans.
These two sections in CHIPRA affect the implementation of benchmark
and benchmark-equivalent plans and thus the ``Analysis of and Responses
to Public Comments'' in section III of this final rule, as well as the
regulation, reflect these changes.
Section 611(a)(2) of CHIPRA changed the heading of section
1937(a)(1)(C) of the Act to replace the term ``Wrap-Around'' with
``Additional'' and to accordingly strike the term ``wrap-around'' in
the text of section 1937(a)(1)(C) of the Act.
Section 611(b) of CHIPRA clarifies the reference to children
receiving foster care under section 1937(a)(2)(B)(viii) to apply to
individuals receiving ``child welfare services,'' not ``aid'' or
``assistance''.
Section 611(c) of CHIPRA requires the Secretary to post on the CMS
Web site and publish in the Federal Register, with respect to benchmark
and benchmark-equivalent plans approved by the Secretary, those
provisions of title XIX of the Act which were determined by the
Secretary as not applicable to the State's benchmark and/or benchmark-
equivalent plan, as well as the reason for such determinations.
II. Provisions of the Proposed Regulations
We published a proposed rule in the Federal Register on February
22, 2008 (73 FR 9714) that implemented the provisions of the DRA of
2005, which amends the Act by adding a new section 1937 related to the
coverage of medical assistance under approved State plans. Under this
new provision, States have increased flexibility under an approved
State plan to define the scope of covered medical assistance by
offering coverage of benchmark or benchmark-equivalent benefit packages
to certain Medicaid-eligible individuals. For a complete and full
description of the States' Medicaid Benefit Packages provisions as
required by the DRA, see the February 2008 State Flexibility for
Medicaid Benefit Packages proposed rule. In the February 2008 proposed
rule, we proposed to add a new subpart C beginning with Sec. 440.300
as follows:
A. Subpart C--Benchmark Packages: General Provisions Sec. 440.300,
Sec. 440.305, and Sec. 440.310 Basis, Scope, and Applicability
At proposed Sec. 440.300 (Basis), Sec. 440.305 (Scope), and Sec.
440.310 (Applicability), the regulations would reflect the statutory
authority for States to provide medical assistance to individuals,
within one or more groups of Medicaid eligible individuals specified by
the State, through enrollment in benchmark coverage or benchmark-
equivalent coverage. A State may only require that individuals obtain
benefits by enrolling in that coverage if they are a ``full benefit
eligible'' whose eligibility is based on an eligibility category under
section 1905(a) of the Act that would have been covered under the
State's plan on or before February 8, 2006, and are not within exempted
categories under the statute. The proposed regulatory definition of
full benefit eligible individuals would include individuals who would
otherwise be eligible to receive the standard full Medicaid benefit
package under the approved Medicaid State plan, but would not include
individuals who are within the statutory exemptions, who are determined
eligible by the State for medical assistance under section
1902(a)(10)(C) of the Act or by reason of section 1902(f) of the Act,
or who are otherwise eligible based on a reduction of income due to
costs incurred for medical or other remedial care (other medically
needy and spend-down populations).
B. Section 440.315 Exempt Individuals
Proposed Sec. 440.315 would reflect statutory limitations on
mandatory enrollment of specified categories of individuals. A State
may not require enrollment in a benchmark or benchmark-equivalent
benefit plan by the following individuals:
An individual who is a pregnant woman who is required to
be covered under the State plan under section 1902(a)(10)(A)(i) of the
Act.
An individual who qualifies for medical assistance under
the State plan
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on the basis of being blind or disabled (or being treated as being
blind or disabled) without regard to whether the individual is eligible
for SSI benefits under title XVI on the basis of being blind or
disabled and including an individual who is eligible for medical
assistance on the basis of section 1902(e)(3) of the Act.
An individual who is entitled to benefits under any part
of Medicare.
An individual who is terminally ill and is receiving
benefits for hospice care under title XIX.
An individual who is an inpatient in a hospital, nursing
facility, intermediate care facility for the mentally retarded, or
other medical institution, and is required, as a condition of receiving
services in such institution under the State plan, to spend for costs
of medical care all but a minimal amount of the individual's income
required for personal needs.
An individual who is medically frail or otherwise an
individual with special medical needs (as described by the Secretary in
section 440.315(f)). For purposes of this section, we proposed that
individuals with special needs includes those groups defined by Federal
regulations at Sec. 438.50(d)(1) and Sec. 438.50(d)(3) of the managed
care regulations (that is, dual eligibles and certain children under
age 19 who are eligible for SSI; eligible under section 1902(e)(3) of
the Act, TEFRA children; children in foster care or other out of home
placement; or children receiving foster care or adoption assistance).
We did not propose a definition for medically frail populations but we
invited public comments to assist us in defining this term in the final
regulation.
An individual who qualifies for Medicaid based on medical
condition for medical assistance for long-term care services described
in section 1917(c)(1)(C) of the Act.
An individual who receives aid or assistance under part B
of title IV for children in foster care or an individual with respect
to whom adoption or foster care assistance is made available under part
E of title IV, without regard to age.
An individual who qualifies for medical assistance on the
basis of eligibility to receive assistance under a State plan funded
under part A of title IV (as in effect on or after the welfare reform
effective date defined in section 1931(i) of the Act). This provision
includes those individuals who qualify for Medicaid solely on the basis
of qualification under the Temporary Assistance for Needy Families
(TANF) rules (that is, the State links Medicaid eligibility to TANF
eligibility).
An individual who is a woman receiving medical assistance
by virtue of the application of sections 1902(a)(10)(ii)(XVIII) and
1902(a) of the Act. This provision relates to those individuals who are
eligible for Medicaid based on the breast or cervical cancer
eligibility provisions.
An individual who qualifies for medical assistance as a
TB-infected individual on the basis of section 1902(a)(10)(A)(ii)(XII)
of the Act.
Individuals who are only eligible for Medicaid coverage of
the care and services necessary for the treatment of an emergency
medical condition in accordance with section 1903(v) of the Act.
C. Section 440.320 State Plan Requirements: Optional Enrollment for
Exempt Individuals
At proposed Sec. 440.320, we would allow States to offer exempt
individuals specified in Sec. 440.315 the option to enroll into a
benchmark or benchmark-equivalent benefit plan. The State would
identify in its State plan the exempt groups for which this coverage is
available. There may be instances in which an exempt individual may
benefit from enrolling in a benchmark or benchmark-equivalent benefit
package. States would be permitted to elect in the State plan to offer
exempt individuals a benchmark or benchmark-equivalent package, but
States may not require them to enroll in one. For example, in some
States the State employee benchmark coverage may be more generous than
the State Medicaid plan. Secretary-approved coverage may offer the
opportunity for disabled individuals to obtain integrated coverage for
acute care and community-based long-term care services. Additionally,
States may be able to improve the integration of disease management
programs to provide better coordinated care that targets the specific
needs of individuals with special health needs.
D. Section 440.325 State Plan Requirements: Coverage and Benefits
At proposed Sec. 440.325, we set forth the conditions under which
a State may offer enrollment to exempt individuals specified in Sec.
440.315. When a State offers exempt individuals the option to enroll in
a benchmark or benchmark-equivalent benefit package, the State would
inform the individuals that enrollment is voluntary and that the
individual may disenroll from the benchmark or benchmark-equivalent
benefit package at any time and regain immediate eligibility for the
standard full Medicaid program under the State plan. The State would
inform the individual of the benefits available under the benchmark or
benchmark-equivalent benefit package and provide a comparison of how
they differ from the benefits available under the standard full
Medicaid program. The State would document in the individual's
eligibility file that the individual was informed in accordance with
this paragraph and voluntarily chose to enroll in the benchmark or
benchmark-equivalent benefit package.
At proposed Sec. 440.325, a State would have the option to choose
the benchmark or benchmark-equivalent coverage packages offered under
the State's Medicaid plan. A State may select one or all of the
benchmark plans described in Sec. 440.330 or establish benchmark-
equivalent plans described in Sec. 440.335, respectively.
E. Section 440.330 Benchmark Health Benefits Coverage
At proposed Sec. 440.330, benchmark coverage is described as any
one of the following:
Federal Employees Health Benefit Plan Equivalent Coverage
(FEHBP--Equivalent Health Insurance Coverage). A benefit plan
equivalent to the standard Blue Cross/Blue Shield preferred provider
option service benefit plan that is described in and offered to Federal
employees under 5 U.S.C. 8903(1).
State employee coverage. A health benefits plan that is
offered and generally available to State employees in the State
involved.
Health Maintenance Organization (HMO) plan. A health
insurance plan that is offered through an HMO (as defined in section
2791(b)(3) of the Public Health Service Act) that has the largest
insured commercial, non-Medicaid enrollment in the State.
Secretary-approved coverage. Any other health benefits
coverage that the Secretary determines, upon application by a State,
provides appropriate coverage for the population proposed to be
provided that coverage. As proposed, States wishing to opt for
Secretarial-approved coverage should submit a full description of the
proposed coverage and include a benefit-by-benefit comparison of the
proposed plan to one or more of the three benchmark plans specified
above or to the State's standard full Medicaid coverage package under
section 1905(a) of the Act, as well as a full description of the
population that would be receiving the coverage. In addition, the State
should submit any other information that would be relevant to a
determination that the proposed health benefits coverage would be
appropriate for the
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proposed population. The scope of a Secretary approved health benefits
package will be limited to benefits within the scope of the categories
available under a benchmark coverage package or the standard full
Medicaid coverage package under section 1905(a) of the Act.
A State may select one or more benchmark coverage plan options. The
State may also specify the benchmark plan for any specific individual.
For example, one individual may be enrolled in the FEHBP-equivalent and
another may be enrolled into State Employee Coverage at the option of
the State.
F. Section 440.335 Benchmark-Equivalent Health Benefits Coverage
At proposed Sec. 440.335, we proposed to provide that if a State
designs or selects a benchmark plan other than those specified in Sec.
440.330, the State must provide coverage that is equivalent to
benchmark coverage. Coverage that meets the following requirements will
be considered to be benchmark-equivalent coverage:
Required Coverage. Benchmark-equivalent coverage includes
benefits for items and services within each of the following categories
of basic services and must include coverage for the following
categories of basic services:
+ Inpatient and outpatient hospital services.
+ Physicians' surgical and medical services.
+ Laboratory and x-ray services.
+ ``Well-baby'' and ``well-child'' care, including age-appropriate
immunizations.
+ Other appropriate preventive services, as designated by the
Secretary.
Aggregate actuarial value equivalent to benchmark
coverage. Benchmark-equivalent coverage must have an aggregate
actuarial value, determined in accordance with proposed Sec. 440.340,
that is at least equivalent to coverage under one of the benchmark
packages outlined in Sec. 440.330.
Additional coverage. In addition to the categories of
services set forth above, benchmark-equivalent coverage may include
coverage for any additional services included in the benchmark plan or
described in section 1905(a) of the Act.
Application of actuarial value for benchmark-equivalent
coverage that includes prescription drugs, mental health, vision, and
hearing services. Where the benchmark coverage package used by the
State as a basis for comparison in establishing the aggregate actuarial
value of the benchmark-equivalent package includes any or all of the
following four categories of services: Prescription drugs; mental
health services; vision services; and hearing services; then the
actuarial value of the coverage for each of these categories of service
in the benchmark-equivalent coverage package must be at least 75
percent of the actuarial value of the coverage for that category of
service in the benchmark plan used for comparison by the State.
If the benchmark coverage package does not cover one of the four
categories of services mentioned above, then the benchmark-equivalent
coverage package may, but is not required to, include coverage for that
category of service.
G. Section 440.340 Actuarial Report for Benchmark-Equivalent Health
Benefit Coverage
In accordance with 1937(a)(3) of the Act, at Sec. 440.340, we
proposed to require a State, as a condition of approval of benchmark-
equivalent coverage, to provide an actuarial report, with an actuarial
opinion that the benchmark-equivalent coverage meets the actuarial
requirements of Sec. 440.335.
At Sec. 440.340, we proposed to require the actuarial report to
obtain approval for benchmark-equivalent health benefit coverage and to
meet all the provisions of the statute. The actuarial report must state
the following:
The actuary issuing the opinion is a member of the
American Academy of Actuaries (AAA) (and meets Academy standards for
issuing an opinion).
The actuary used generally accepted actuarial principles
and methodologies of the AAA, standard utilization and price factors
and a standardized population representative of the population
involved.
The same principles and factors were used in analyzing the
value of different coverage (or categories of services) without taking
into account differences in coverage based on the method of delivery or
means of cost control or utilization used.
The report should also state if the analysis took into
account the State's ability to reduce benefits because of the increase
in actuarial value of health benefits coverage offered under the State
plan that results from the limitations on cost sharing (with the
exception of premiums) under that coverage.
The actuary preparing the opinion must select and specify
the standardized set of utilization and pricing factors as well as the
standardized population.
The actuary preparing the opinion must provide sufficient
detail to explain the basis of the methodologies used to estimate the
actuarial value or, if requested by CMS, to replicate the State's
result.
H. Section 440.345 EPSDT Services Requirement
At Sec. 440.345, we proposed to require States to make available
EPSDT services as defined in section 1905(r) of the Act that are
medically necessary for those individuals under age 19 who are covered
under the State plan. We expected that most benchmark or benchmark-
equivalent plans will offer the majority of EPSDT services. To the
extent that any medically necessary EPSDT services are not covered
through the benchmark or benchmark-equivalent plan, States are required
to supplement the benchmark or benchmark-equivalent plan in order to
ensure access to these services. As proposed, individuals mandated into
a benchmark or benchmark-equivalent plan and entitled to have access to
EPSDT services cannot disenroll from the benchmark or benchmark-
equivalent plan just to receive these services. While, as proposed,
individuals are required to have access to such medically necessary
services first under the benchmark or benchmark-equivalent plan, the
State may provide wrap-around or additional coverage for medically
necessary services not covered under such plan. Any wrap-around
benefits must be sufficient so that, in combination with the benchmark
or benchmark-equivalent benefits package, an individual would have
coverage for his or her medically necessary services consistent with
the requirements under section 1905(r) of the Act. The State plan would
include a description of how wrap-around benefits or additional
services will be provided to ensure that these individuals have access
to full EPSDT services under section 1905(r) of the Act.
In addition, as proposed, individuals would need to first seek
coverage of EPSDT services through the benchmark or benchmark-
equivalent plan before seeking coverage of such services through other
options established by the State for receiving wrap-around benefits
under section 1937 of the Act.
I. Section 440.350 Employer Sponsored Insurance Health Plans
At Sec. 440.350, we proposed that the use of benchmark or
benchmark-equivalent benefit coverage would be at the discretion of the
State and may be used in conjunction with employer sponsored health
plans as a coverage option for individuals with access to private
health insurance. Additionally, the use of benchmark or benchmark-
equivalent coverage may be used for
[[Page 23072]]
individuals with access to private health insurance coverage. For
example, if an individual has access to employer sponsored coverage and
that coverage is determined by the State to be benchmark or benchmark-
equivalent, a State may, at its option, provide premium payments on
behalf of the individual to purchase the employer coverage.
Additionally, a State could create a benchmark or benchmark-equivalent
plan combining employer sponsored insurance and wrap-around benefits to
that employer sponsored insurance benefit package. The premium payments
would be considered medical assistance and the State could require the
non-exempt individual to enroll in the group health plan.
J. Section 440.355 Payment of Premiums
At Sec. 440.355, we proposed that payment of premiums by the
State, net of beneficiary contributions, to obtain benchmark or
benchmark-equivalent benefit coverage on behalf of beneficiaries under
this section will be treated as medical assistance under section
1905(a) of the Act.
K. Section 440.360 State Plan Requirement for Providing Additional
Wrap-Around Services
At Sec. 440.360, we proposed that a State may at its option
provide additional wrap-around services to the benchmark or benchmark-
equivalent plans. The wrap-around services do not need to include all
State plan services. However, the State plan would be required to
describe the populations covered and the payment methodology for
assuring those services. Such additional or wrap-around services must
be within the scope of categories of services covered under the
benchmark plan, or described in section 1905(a) of the Act.
L. Section 440.365 Coverage of Rural Health Clinic and Federally
Qualified Health Center (FQHC) Services
At Sec. 440.365, we proposed that a State that provides benchmark
or benchmark-equivalent coverage to individuals must assure that the
individual has access, through that coverage or otherwise, to rural
health clinic services and FQHC services as defined in subparagraphs
(B) and (C) of section 1905(a)(2) of the Act. Payment for these
services must be made in accordance with the payment provisions of
section 1902(bb) of the Act.
M. Section 440.370 Cost Effectiveness
At Sec. 440.370, we proposed that benchmark or benchmark-
equivalent coverage and any additional benefits must be provided in
accordance with Federal upper payment limits, procurement requirements
and other economy and efficiency principles that would otherwise be
applicable to the services or delivery system through which the
coverage and benefits are obtained.
N. Section 440.375 Comparability
At Sec. 440.375, we proposed that a State may at its option amend
its State plan to provide benchmark or benchmark-equivalent coverage to
individuals without regard to comparability.
O. Section 440.380 Statewideness
At Sec. 440.380, we proposed that a State may at its option amend
its State plan to provide benchmark or benchmark-equivalent coverage to
individuals without regard to statewideness.
P. Section 440.385 Freedom of Choice
At Sec. 440.385, we proposed that a State may at its option amend
its State plan to provide benchmark or benchmark-equivalent coverage to
individuals without regard to freedom of choice. States may restrict
individuals to obtaining services from (or through) selectively
procured provider plans or practitioners that meet, accept, and comply
with reimbursement, quality and utilization standards under the State
Plan, to the extent that the restrictions imposed meet the following
requirements:
(+) Do not discriminate among classes of providers on grounds
unrelated to their demonstrated effectiveness and efficiency in
providing the benchmark benefit package.
(+) Do not apply in emergency circumstances.
(+) Require that all provider plans are paid on a timely basis in
the same manner as health care practitioners must be paid under Sec.
447.45 of the chapter.
Q. Section 440.390 Assurance of Transportation
At Sec. 440.390, we proposed that a State may at its option amend
its State plan to provide benchmark or benchmark-equivalent coverage to
individuals without regard to the assurance of transportation to
medically necessary services requirement specified in Sec. 431.53.
III. Analysis of and Responses to Public Comments
In response to the February 2008 proposed rule, we received over
1,100 timely items of correspondence. In response to the February 2,
2009 interim final rule with a 30-day comment period (the first
temporary delay of the December 3, 2008 final rule), we received nine
timely items of correspondence. In response to the April 3, 2009
interim final rule with a 30-day comment period (the second temporary
delay of the December 3, 2008 final rule), we received seven timely
items of correspondence. In response to the October 30, 2009 proposed
rule on delaying the effective date of the final rule to July 1, 2010,
we received one timely item of correspondence.
The majority of the comments received on the proposed rule
represented transportation providers, medical providers, and Medicaid
beneficiaries, particularly Medicaid beneficiaries who rely on dialysis
treatments. Other comments represented State and local advocacy groups,
national associations that represent various beneficiary sub-groups,
State Medicaid agency senior officials, and human services agencies. In
this section, we provide a discussion of the public comments we
received on the February 22, 2008 proposed rule, the February 2, 2009
interim final rule with a 30-day comment period (the first temporary
delay of the December 3, 2008 final rule) and the April 2, 2009 final
rule with a 30-day comment period (the second temporary delay of the
December 3, 2009 final rule), as well as the one comment that we
received in response to our October 30, 2009 proposed rule delaying the
effective date of the December 3, 2008 final rule, which addressed the
issue of revisions required to comply with statutory changes. Comments
related to the impact of this rule are addressed in the ``Collection of
Information Requirements'' section of this regulation.
Additionally, we published a proposed rule in the Federal Register
on February 22, 2008 (73 FR 9727) titled, ``Medicaid Program: Premiums
and Cost Sharing'' (CMS-2244-P). Comments on CMS-2244-P were also due
March 24, 2008 similar to this rule. Some comments for CMS-2244-P were
forwarded as comments to this rule (CMS-2232-P). Consistent with the
Administrative Procedures Act, CMS is not responding to those comments
in this regulation, but we addressed the issues raised by otherwise
timely
[[Page 23073]]
comments in our publication of CMS-2244-F.
A. General Comments
Comments: A few commenters supported the proposed rule and a few
commenters strongly supported certain provisions of the December 3,
2008 rule. However, most commenters oppose either the February 22, 2008
proposed rule or certain sections of the December 3, 2008 rule. Many
commenters are concerned that the benchmark or benchmark-equivalent
benefit packages are inadequate benefit packages for, among others,
individuals with mental illness, children with serious emotional
disturbance, the disabled and elderly, individuals with end stage renal
disease, and American Indians. Many of the commenters believe that to
enroll Medicaid beneficiaries in benchmark or benchmark-equivalent
benefit packages without the assurance of transportation could lead to
poorer health outcomes, costlier care because individuals will be
forced into hospital emergency rooms, and shifts in costs to the
Emergency Medical Services.
Response: We acknowledge and appreciate the views of the commenters
who both supported and opposed the February 22, 2008 proposed rule and
the December 3, 2008 rule. Those who opposed the rule generally raised
concerns about the underlying wisdom of the statutory provision at
section 1937 of the Act, which this final rule implements. CMS is
charged with implementing the statute. We address comments relating to
restrictive interpretations below in the discussion of specific
proposed provisions that arguably were not required by the statutory
provision.
Comment: Several commenters believe that the accelerated pace of
the short comment period for the proposed rule, given the broad
implications, will lead to a short-sighted, onerous rule that has
dangerous health impacts for the poor. The proposed rule was issued in
the Federal Register on February 22, 2008. The deadline for submission
of comments was March 24, 2008. The commenters stated that other
rulemaking has taken a longer period and that given the impact of the
provisions, a longer time period is warranted.
Some commenters stated that the 30-day comment period in the
proposed rule was not sufficient for Tribes to comment on a regulation
that could potentially have a significant impact on Tribal communities.
Other commenters noted that while the Department views the proposed
rule as merely formalizing its earlier policy statements delivered only
to State Medicaid Directors, a 30-day public comment period is too
short for meaningful public review, analysis, and comment. Some
commenters believe that the 30-day comment period is discouraging of
full review and consideration by States.
One commenter requests that the public comment period be extended
by 60 days for a total of a 90-day comment period. Additional time is
needed to provide sufficient time for stakeholders to be able to
adequately assess the potential effects of the proposed rule.
Response: As described in the ``Background'' in section I of this
regulation under ``Regulatory History,'' in section I.A. of this
regulation a 30-day public comment period on the February 22, 2008
proposed rule was provided and two additional 30-day public comment
periods were provided on the December 3, 2008 rule. We believe that
these comment periods allowed sufficient time for public comment.
B. Section 440.300 Basis
Comment: One commenter believed that the proposed limitations on
eligibility groups who can be provided alternative benefit packages are
overly restrictive. The commenter suggested that the rule should allow
application to any eligibility category the State had the option to
implement on or before the date of enactment of section 1937 (February
8, 2006). The commenter reasoned that States are continually adding and
changing eligibility requirements and these program changes are
inherent in Medicaid programs. The commenter asserted that, if the rule
is considered beneficial for individuals in eligibility categories that
existed before February 8, 2006, it is logical to suppose it would also
be beneficial for those created after that date.
Response: The language in section 1937(a)(1)(B) of the Act
specifies that the State may only exercise the option to offer
benchmark or benchmark-equivalent coverage for an individual eligible
under an eligibility category that had been established under the State
plan on or before February 8, 2006. We have interpreted this statutory
term to mean any eligibility category listed under section 1905(a) of
the Act. Thus, all individuals within a category covered or potentially
covered under the State's Medicaid plan could be eligible to
participate in a benchmark or benchmark-equivalent plan at the State's
option, unless specifically excluded by statute, even when the State
makes modifications to the income and resource eligibility levels or
methodologies, ages covered, etc. for a group or category after
February 8, 2006.
C. Section 440.305 Scope
Comment: Numerous commenters believed that offering benchmark and
benchmark-equivalent benefit packages to certain Medicaid individuals
will deter those individuals, including children, from receiving
appropriate care. Commenters indicated that individuals with low
incomes are likely to forego needed treatment if all medically
necessary services and transportation are not included in the benchmark
program. Most commenters believed that our most vulnerable populations,
those with chronic medical needs, will be required to choose to provide
for their basic needs like food and shelter rather than obtain
necessary medical health care because of the rigor created by following
a private health insurance model of benefits and the need to provide
their own method of transportation.
Response: The benchmark and benchmark-equivalent coverage was
authorized by the statute. Under the statute, the benchmark flexibility
is an option that States can choose to use in redesigning their current
Medicaid benefit program. It should be noted that as a result of the
CHIPRA changes to the DRA, this option is not as broad as it had been
and we have revised the regulations to comply with CHIPRA by stating
that States must comply with all requirements of title XIX other than
sections 1902(a)(1) and 1902(a)(10(B) of the Act, unless such
requirement can be shown to be directly contrary to the authority under
section 1937 of the Act. For example, under the CHIPRA changes
transportation is a required service and benchmark plans utilizing
managed care delivery systems must meet managed care rules.
Comment: Other commenters indicated that the DRA does not require
that States offer the same Medicaid benefits statewide, meaning States
could design different benefit packages for rural and urban areas.
States may also ``tailor'' packages for different populations, although
the commenter acknowledges, certain groups are exempt from mandatory
changes to their Medicaid benefits package. In States where this has
already been done, there have been some reports that the changes have
been unsatisfactory. Several commenters believed that allowing States
to ``tailor'' benefit packages would mean that individuals may not have
access to the services they need. Benefit packages designed outside the
important consumer protections in
[[Page 23074]]
traditional Medicaid may fail to meet beneficiaries' needs, and will
not save money if these individuals experience significant unmet needs
that escalate into problems that require treatment in emergency rooms.
One commenter mentioned that private health plans, such as those
listed as benchmarks under the law, frequently have limited coverage of
mental health services. The commenter asserted that few cover any of
the intensive community services that are covered by Medicaid under the
rehabilitation category or the home and community-based services
option. The commenter noted that, under the DRA, these limited mental
health benefits can be further reduced by 25 percent of their actuarial
value. Other commenters expressed concern that the reliance on
commercial benefit plans is inappropriate for Medicaid individuals.
Those commenters are concerned that many private insurance plans do not
provide adequate mental health services. Other commenters noted that
benchmark coverage is likely to prove entirely inadequate for
individuals who need mental health services. The commenters noted that
children with serious mental and/or physical disorders often qualify
for Medicaid on a basis of family income and are not, for various
reasons, receiving Supplemental Security Income (SSI) benefits or
otherwise recognized as children with disabilities and would not be
exempt from mandatory enrollment. In addition, the commenters noted
that many low-income parents on Medicaid have been found to have
serious depression, which could not be adequately treated with a very
limited mental health benefit.
Similarly, many commenters believed that the proposed rule has the
potential to become the behavioral healthcare Medicaid ``Trojan
horse'': It appears harmless but it will reverse hard fought progress
won over years of struggle that brought about equitable, decent care
for Medicaid-eligible individuals experiencing mental illness or who
have a developmental disability. The commenters asserted that, in the
end, these rules will have costlier results and not the desired
economizing while also negatively impacting peoples' lives, their well-
being and care, and our society.
Another commenter believed that it is critical for beneficiaries
with life-threatening conditions such as HIV/AIDS to maintain access to
the comprehensive range of medical and support services required to
effectively manage HIV disease. The commenter stated that allowing
States to ``tailor'' benefit packages in ways that essentially
eliminate coverage for critical health services places the health of
Medicaid beneficiaries with HIV/AIDS in serious jeopardy.
Response: The DRA created section 1937 in response to States'
desire for more flexibility in designing their Medicaid programs and
adopting benefit programs tailored to the needs of the varied
populations they serve. The DRA provides that States can provide
alternative benchmark or benchmark-equivalent benefit packages at their
option; that is, States are not required to implement these provisions.
We have incorporated elements in this regulation that are designed to
protect vulnerable populations and to help assure that individuals
enrolled in a benchmark benefit plan will have access to services that
are appropriate to their individual needs to the extent permitted by
the statute.
To protect individuals with disabilities we have included in this
rule a basic minimum definition of medically frail and special medical
needs to insure that people with disabilities and special health care
needs are not mandatorily enrolled in benchmark benefit plans. Rather,
they can only be voluntarily enrolled after being fully informed of the
differences between the benchmark benefit plan and the traditional
State plan. We have added language at Sec. 440.305(b)(2) that requires
States electing to offer benchmark benefit plans or wishing to
substantively change an approved benchmark benefit plan to provide
advance public notice with an opportunity to comment. Before submitting
to CMS a State plan amendment to implement a benchmark benefit plan or
an amendment to substantially modify the benefits or eligibility
provisions of an approved benchmark benefit plan, the State must first
provide the public the opportunity to review the proposed change and
comment on it.
We acknowledge and agree with the commenters on the importance of
providing adequate mental health benefits and will be separately
addressing how post DRA-enactments, specifically the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
relate to benchmark benefits.
The new benefit option provides States with additional tools to
provide care to maximize health outcomes for certain individuals. These
tools may be used in conjunction with other Medicaid and Children's
Health Insurance Program (CHIP) authorities to strategically align the
Medicaid program with the current health care environment and expand
access to care by leveraging existing benefit and coverage options to
improve quality and coordination of care.
States seeking to use benchmark and benchmark-equivalent plans to
provide coverage for children and adults with special medical needs,
individuals with HIV/AIDS, and long-term care and community-based
service options, must design a benchmark benefit package that is
appropriate to meet the health care needs of the population being
served, including coverage that may be more generous than a State's
Medicaid plan.
We think it is important to note that States are required to
provide children under the age of 21 with EPSDT services either as an
additional service and or as part of the benchmark or benchmark-
equivalent benefit plan. States are required to inform families about
how and where to access these services particularly if the benchmark or
benchmark-equivalent benefit does not identify the full range of EPSDT
services needed by the beneficiary as being covered. States must assure
that these services are provided in the most seamless way possible and
the families understand how to access such services through the
Medicaid State plan.
Moreover, certain groups cannot be included in a mandatory
enrollment for an alternative benefit package--among others, pregnant
women, dual eligibles, terminally ill individuals receiving hospice,
inpatients in institutional settings, and individuals who are medically
frail or have special medical needs. These individuals may be offered a
choice to enroll and, in considering the choice, must be provided a
comparison of benchmark benefits versus the traditional Medicaid State
plan benefit. Their decision to enroll is voluntary and individuals
must be provided the opportunity to revert back to traditional Medicaid
at any time.
Comment: One commenter noted that the preamble language refers to
meeting the ``* * * needs of today's Medicaid populations and the
health care environment.'' The commenter believed the preamble should
describe these needs in some detail so that there is a shared
understanding of the types of needs this new flexibility is intended to
address.
Response: We agree that it is important to understand the needs of
today's Medicaid populations and the health care environment. Congress
has provided States with the flexibility to align Medicaid benefit
packages for certain populations with commercial insurance plans.
States now have the ability to provide additional services that are
uniquely designed to meet the
[[Page 23075]]
needs of targeted populations. For example, individuals with asthma and
chronic obstructive pulmonary disease who reside in a certain area of
the State may be offered disease management services which are not
otherwise available under the traditional State plan to all individuals
with asthma and chronic obstructive pulmonary disease. A State may
elect to provide beneficiaries with incentives for healthy behavior by
offering additional services. For example, a State could offer certain
(enhanced) preventive services not available under the regular State
plan, such as smoking cessation counseling or nutritional/dietary
management, to beneficiaries with certain medical conditions and/or in
certain parts of the State. Prior to the enactment of the DRA, a State
that wanted to tailor its Medicaid program to meet the unique needs of
its beneficiaries would have to utilize a demonstration or waiver
program.
Comment: One commenter stated that the proposed rule, read together
with other CMS rules like the citizenship documentation requirement and
CMS's Children's Health Insurance Program (CHIP) crowd-out directive of
August 17, 2007, create major barriers to access to appropriate health
care, and that the proposed rule has a devastating impact on the low
income populations. In particular, some commenters raised concerns
about requirements for American Indians and Alaska Natives to prove
both citizenship and identity in order to obtain Medicaid services.
Commenters also raised concerns about the CHIP review strategy outlined
in an August 17, 2007 letter sent to State Health Officials. Commenters
also asserted that other proposed rules released by CMS like the
Rehabilitation Rule and the Targeted Case Management Rule coupled with
this rule will have a devastating effect on individuals in need of
transportation since these rules also eliminate non-emergency medical
transportation services.
Response: We agree that the DRA benchmark rules can create some
risk that beneficiaries may not be able to access needed care, and we
will implement the rules mindful of this possibility and consistent
with the Federal law. Additionally, CHIPRA included two significant
technical changes to the DRA that amended section 1937 of the Act. In
order to reflect these changes, we modified the regulation at Sec.
440.390 to clarify that States must assure necessary transportation to
and from providers and at Sec. 440.345 to clarify that States must
assure that children under the age of 21 who are enrolled in
alternative benefit plans must have full access to EPSDT services.
Additionally, we expanded paragraph (b)(5) in Sec. 440.335, which
lists the mandatory services that benchmark-equivalent plans must
provide, to include family planning services and supplies as a required
preventive service.
Citizenship documentation requirements and the rehabilitation and
case management requirements are not part of this rule and we do not
address them here. This regulation implements the statutory provisions
of section 1937 of the Act. However, it should be noted that the August
17, 2007 State Health Officials letter on CHIP eligibility levels and
crowd out was withdrawn on February 4, 2009, at the direction of
President Obama. The CHIPRA, signed into law on that same day, provides
new flexibility to States for streamlining citizenship documentation.
CHIPRA also includes technical amendments to the DRA which clarify
documentation requirements, provide for a reasonable opportunity period
for individuals to submit such documentation, and expand the list of
documents that are acceptable for verifying citizenship.
Comment: Several comments were provided by organizations that have
an interest in how the benchmark and benchmark-equivalent benefit
packages impact American Indians/Alaska Natives. The commenters
believed that alternative benefit packages serve as a substantial
barrier to American Indians/Alaska Natives enrollment in the Medicaid
program. They noted that, because of the Federal government's trust
responsibility to provide health care to American Indians/Alaska
Natives, implementing benchmark and benchmark-equivalent benefit
packages have specific tribal implications that were not addressed in
the proposed rule. Several commenters believed that American Indians/
Alaska Natives should be exempt from mandatory enrollment in benchmark
and benchmark-equivalent benefit programs entirely.
Response: In Medicaid, there is no statutory basis to exempt
American Indians/Alaska Natives from Medicaid alternative benefit
provisions. Section 1937 of the Act does not provide for such an
exemption. Section 1937 does provide some specific exemptions from
mandatory enrollment in benchmark or benchmark-equivalent benefit
packages and it is possible that some American Indians/Alaska Natives
would fit into one of these exempt groups. Section 1937 does not
however give CMS authority to identify additional exempt groups.
To address the unique needs of the American Indians/Alaska Natives
population, we expect States to ensure that alternative benefit
packages recognize the unique services offered by IHS and tribal
providers, and the unique health needs of the American Indians/Alaska
Natives population. To ensure this, section 5006 of ARRA requires
States to consult with Indian Health Programs or Urban Indian
Organizations that furnish health care services on matters that are
likely to have a direct effect on these health programs. It also
requires that services provided to Indians through managed care
organizations provide access to IHS providers.
Comment: One commenter contended that there are no provisions to
require States to ensure that American Indians/Alaska Natives continue
to have access to culturally competent health services through the
Indian Health Service (IHS) or tribally operated health programs. The
commenter stated that the proposed rules allow States to offer coverage
without regard to comparability, statewideness, freedom of choice, the
assurance of transportation to medically necessary services, and other
requirements. There are large disparities between American Indians/
Alaska Natives' health care status and the health care status of the
rest of the country. The commenter added that for American Indians/
Alaska Natives, the patient should always have the option of the
provider being an Indian Health Service or tribal health program.
Response: State Medicaid programs provide health care services to
many diverse populations including American Indians/Alaska Natives
individuals. We believe that culturally competent services are
important for all Medicaid beneficiaries and access to care and
facilities in remote parts of the country, where it is especially
difficult to find providers who will agree to participate in the
Medicaid program, is paramount. Section 1937 of the Act does not
provide any special protections for benefit packages applicable to
American Indians/Alaska Natives individuals, but this does not mean
that benefit packages will be deficient.
Section 5006(e) of the ARRA, which was signed on February 17, 2009
and became effective July 1, 2009, requires that in the case of any
State in which one or more Indian Health Program or Urban Indian
Organization furnishes health care services, the Medicaid State plan
specify a process under which the State seeks advice from designees of
such programs or organizations on matters that are likely to have a
direct effect on these health programs.
As noted previously, to address the unique needs of the American
Indians/
[[Page 23076]]
Alaska Natives population, we expect States to work with Indian Health
Programs or Urban Indian Organizations that furnish health care
services to ensure that alternative benefit packages recognize the
unique services offered by IHS and tribal providers, and the unique
health needs of the American Indians/Alaska Natives population.
With regard to the assurance of transportation and freedom of
choice of providers, CHIPRA amended the ``notwithstanding any other
provisions of this title'' language. This change in the law clarifies
that the authority under section 1937 of the Act to deviate from
otherwise applicable Medicaid requirements is limited. Therefore, we
revised the regulation at Sec. 440.390 to require States to assure
necessary transportation to and from providers for individuals enrolled
in benchmark and benchmark-equivalent plans and at Sec. 440.385 by
removing the option to provide benchmark and benchmark-equivalent
coverage without regard to freedom of choice of providers. While we do
not anticipate that there will be many requirements of title XIX that
would be contrary to implementing a benchmark benefit plan, States may
request an exemption from a provision of title XIX if they can
demonstrate how the provision would be directly contrary to section
1937 of the Act.
Comment: Another commenter stated on behalf of American Indians/
Alaska Natives, the Indian and tribal health care system is woefully
under-funded and tribal providers rely on Medicaid revenues to
supplement that meager funding. Forcing American Indians/Alaska Natives
into benchmark plans, which may have dramatically reduced coverage or
payments, would thus jeopardize Indian health, injure tribal health
systems, and thereby violate the Federal trust obligation to care for
the health needs of Indian people.
Response: We acknowledge that benchmark plans could reduce covered
benefits. To date, however, CMS has approved ten benchmark benefit
programs, and most offer State plan services plus additional services
like preventive care, personal assistance services, or disease
management services. For individuals under the age of 21, section 1937
of the Act ensures that all needed services will be available through
the requirement that EPSDT services must be provided either in addition
to, or as part of, the benchmark or benchmark-equivalent plan.
Section 1937 of the Act does not provide a basis to exclude IHS or
tribal health providers from participation in the delivery system for
alternative benefits. Futhermore, CMS does not determine IHS funding
levels.
In an effort to reach out to Tribes we held several discussions
with Tribes about the changes made to the DRA and section 1937 of the
Act by section 611 of CHIPRA. These discussions took place during the
All Tribes call on July 2, 2009, and during two face to face open
consultation meetings held with Tribes on July 8th and July 10th, 2009.
We covered all CHIPRA related issues, including the changes made to
section 1937 of the Act during all of these meetings. Also, on June 29,
2009 we covered section 611 of CHIPRA during the Tribal Technical
Advisory Group (T-TAG) meeting CMSO had with the T-TAG policy advisors.
CMS is committed to enhancing communication with Tribes and to assuring
that the obligation of States to consult with American Indians/Alaska
Natives on all issues affecting Indian health services are followed by
State Medicaid agencies.
Comment: Some commenters believed that the proposed rule did not
comply with the Department of Health and Human Services' Tribal
Consultation policy, since CMS did not consult with Tribes in the
development of these regulations before they were promulgated.
These commenters noted that CMS did not obtain advice and input
from the CMS Tribal Technical Advisory Group (TTAG), even though the
TTAG meets on a monthly basis through conference calls and holds
quarterly face to face meetings in Washington, DC. They also noted that
CMS did not utilize the CMS TTAG Policy Subcommittee, which was
specifically established by CMS for the purpose of obtaining advice and
input in the development of policy guidance and regulations.
These commenters also noted that the proposed rule does not contain
a Tribal summary impact statement describing the extent of the tribal
consultation or lack thereof, nor an explanation of how the concerns of
Tribal officials have been met. Several commenters request that these
regulations not be made applicable to American Indians/Alaska Natives
Medicaid beneficiaries until Tribal consultation is conducted, or be
modified to specifically require State Medicaid programs to consult
with Indian Tribes before the development of any policy which would
require mandatory enrollment of American Indians/Alaska Natives in
benchmark or benchmark-equivalent plans. One commenter suggested that
this consultation should be similar to the way in which consultation
takes place with Indian Tribes in the development of waiver proposals.
And, a commenter urged that, after appropriate tribal consultation and
revision reflecting these and other comments, the rule be republished
with a longer public comment period.
One Tribe commented that the proposed rule does not honor treaty
obligations for health services that are required by the Federal
government's unique legal relationship with Tribal governments.
Response: CMS currently operates under the Department of Health and
Human Services' Tribal Consultation Policy. The Departmental guidelines
provide information as to the regulatory activities that rise to the
level that require consultation (include prior notification of
rulemaking). We have considered the Departmental guidelines. Though the
effect on American Indians/Alaska Natives individuals results from the
statute itself, and not this rule, CMS did consult with the Tribes
about the changes made to the DRA and section 1937 of the Act by
section 611 of CHIPRA as described in the previous response.
Section 5006(e) of ARRA, which was signed on February 17, 2009 and
became effective July 1, 2009, provides American Indians/Alaska Natives
individuals with new protections because it requires that Medicaid
State plans specify a process under which the State seeks advice from
designees of Indian Health Programs or Urban Indian Organizations that
furnish health care services on matters that are likely to have a
direct effect on these health programs. States that elect to implement
alternative benefit packages must consult with Tribes and notify them
about State plan amendments that will directly affect the Tribes. These
regulations implement section 1937 of the Act, as enacted by Congress,
and do not address treaty rights of American Indians. These regulations
neither diminish nor increase such treaty rights. Questions about the
Indian Health Services budget should be directed to Indian Health
Services.
Comment: Several commenters believed that States should not have
the ability to create benchmarks that allow for increases in cost
sharing. Specifically, States can establish a benchmark coverage
package that requires co-pays for health care access, whereby the cost
sharing will actually be a limitation on coverage. However, if the
selected benchmark plan indicates that it provides coverage for only
half of the cost of mental health services, CMS views that as a
coinsurance requirement rather than as a limitation on coverage.
[[Page 23077]]
Premiums and cost sharing act as a deterrent to those receiving health
care and may cause low income populations to choose between healthcare
and basic needs such as food. The commenter indicated that American
Indians/Alaska Natives and other low-income groups should be exempt
from premiums and cost-sharing requirements.
Response: States have the option to impose cost sharing in Medicaid
but are limited by the requirements of sections 1916 and 1916A of the
Act. To the extent that these benchmark packages impose premiums or
cost sharing, this final regulation stipulates that any cost sharing
and premiums for individuals may not exceed cost sharing limits
applicable under sections 1916 and 1916A of the Act. In a State that
imposes cost sharing under either 1916 or 1916A the State would be
permitted to apply different cost sharing requirements for individuals
enrolled in the benchmark or benchmark-equivalent plan than it imposes
for those not enrolled in such plans. In some cases individuals
enrolled in benchmark or benchmark-equivalent plans may actually have
lower cost sharing than is required of individuals enrolled in the
traditional State plan benefit package. Under section 1916A of the Act,
there are tiered individual service limits based on family income, and
an aggregate cap of five percent of family income. These limits apply
to all individuals enrolled in benchmark plans.
Section 5006 of ARRA added new protections for American Indians/
Alaska Native related to: premiums and cost sharing; exclusion of
certain American Indians/Alaska Natives specific property from estate
recovery in Medicaid; new rules regarding American Indians/Alaska
Natives, Indian Health Providers and Indian Managed Care entities in
Medicaid; and new consultation requirements for Medicaid, CHIP and
other health care programs funded under the Act involving Indian Health
programs and Urban Indian organizations.
It is important to note that alternative benefit package programs
are provided at the State's option. However, we recognize the concerns
raised by these commenters.
Numerous Medicaid eligibility categories are exempt from mandatory
enrollment in alternative benefit packages and can only select the
alternative benefit package voluntarily. Such individuals must be
provided a comparison of the benchmark option versus the State plan
option before they choose to enroll. That comparison must include
information on the cost-sharing obligations of beneficiaries. In
choosing the benchmark option over the State plan option, these
individuals would thus have actively made an informed choice. Finally,
exempt individuals must be able to revert back to traditional Medicaid
at any time. States electing to offer an alternative benefit package
and choosing to allow voluntary enrollment for exempt populations must
demonstrate how the State will operationalize the disenrollment
provisions as well as provide detailed information on how informed
choice will occur.
Comment: One commenter urged CMS to add provisions to provide
special protections for individuals with disabilities, dual eligibles,
and persons with other chronic medical conditions to ensure access to
benchmark packages that are uniquely designed to address physical
impairments and rehabilitation needs.
Another commenter believed CMS should require State Medicaid
agencies to provide access to care management and care coordination
services to Medicaid individuals who are incapable of managing their
benchmark plan services. The commenter further believed that home
health services should be included in all benchmark plan packages.
Several commenters recommended that all State programs include
prevention services and promote health, wellness, and fitness. Physical
therapists are involved in prevention by promoting health, wellness and
fitness, and in performing screening activities.
One commenter is concerned that the managed care model is better
suited for a ``well'' population as opposed to children with chronic
special health care needs and adults with disabilities.
Response: To the extent that the commenter is concerned that
alternative benefit packages will result in a reduction in services, we
acknowledge that this is a possibility. However, for the benchmark
State plan amendments implemented to date, most offer traditional State
plan services as well as additional services like prevention and
disease management.
States can consider benchmark-equivalent coverage as long as the
coverage includes mandatory services such as inpatient and outpatient
hospital services, physicians' surgical and medical services,
laboratory and x-ray services, emergency services, well-baby and well-
child care including age-appropriate immunizations, and other
appropriate preventive services. We have determined that other
appropriate preventive services must include family planning services
and supplies.
Benchmark-equivalent plans may also include care management, care
coordination, and/or home health services, but it is possible that some
plans will not include these services. We do not agree that a
requirement that States include these specific services would be
consistent with the statute.
An important protection for children enrolled in alternative
benefit packages is the requirement to ensure full access to the EPSDT
benefit for children under the age of 21. If services are not provided
as part of the benchmark or benchmark-equivalent plan, these services
must be provided by the State as additional benefits. States electing
the benchmark benefit option must provide CMS with information
describing how it will inform families of the availability of such
services and how the State will coordinate access to those services
when they must be provided outside of the benchmark plan. Furthermore,
States, at their option, can provide for additional services to
benchmark or benchmark-equivalent programs.
Additionally, exempt individuals must make an informed choice
before they elect to voluntarily enroll in benchmark or benchmark-
equivalent plans. This includes the requirement that States must
provide exempt individuals with a comparison of the benefits included
in the benchmark or benchmark-equivalent plan versus the benefits
included in traditional State plan coverage. The exempt individual has
the right to return to State plan coverage at any time. For example, if
the exempt individual is in need of services not offered in the
benchmark plan, the individual can return to the regular Medicaid
benefit package immediately. In order to assure that exempt individuals
voluntarily choose to enroll in a benchmark benefit plan, we revised
Sec. 440.320 to require States to track the number of voluntary
enrollments and disenrollments in benchmark benefit plans by exempt
individuals. Section 440.320 also requires States to act promptly on
requests from exempt individuals for disenrollment and to ensure that
these individuals have full access to standard State plan services
while disenrollment requests are being processed.
Comment: One commenter said the provisions of the regulation on
exempting populations and covering benefits should be consistent with
the Americans with Disabilities Act (ADA).
Response: While exempt populations under this regulation are
specified in section 1937 of the Act and CMS does not have authority
under the statute to expand the definition of exempt
[[Page 23078]]
populations through the regulatory process, we would consider any
implications of the ADA when reviewing a benchmark plan amendment and
in monitoring implementation of the option by a State.
Comment: One commenter believed current regulations governing
managed care in Medicaid that describe the information States must
provide and how that information should be provided should be
incorporated in the rule governing benchmark benefit plans. The
information should include a comparison of features between Medicaid
and the benchmark plan, whenever they differ.
Other commenters urged CMS to allow States to deviate from the
lock-in provisions of Medicaid managed care regulations at 42 CFR part
438. They assert that, if beneficiaries covered by an alternative
benefit package, rather than full Medicaid benefits, can pick and
choose benefits during an enrollment period by plan-hopping, plans will
have no way to establish cost-effective premiums tied to the limited
benefit package. The commenters requested that CMS allow States
providing alternate benefit packages to offer as little as a 30-day
change period after initial assignment, and differences in covered
benefits be excluded as a justifiable cause for beneficiaries to switch
health plans after the change period.
Response: In light of the statutory changes made by CHIPRA, we
revised the regulation at Sec. 440.305 to incorporate compliance with
Medicaid managed care requirements at section 1932 of the Act and at 42
CFR part 438 of Federal regulations. Thus, in providing information to
beneficiaries who are offered managed care plans to obtain alternate
benefit coverage, States are required to comply with the requirements
at 42 CFR 438.10, and therefore must provide all enrollment notices,
informational materials, and instructional materials relating to the
enrollees and potential enrollees in a manner and format that may be
easily understood. This informational material must include, among
other things, information concerning enrollment rights and protections;
any restrictions on freedom of choice among providers; procedures for
obtaining benefits including prior authorization requirements;
information on grievances and fair hearings procedures; information on
physicians, the amount, duration, and scope of benefits; cost sharing,
if any, and the process and procedures for obtaining emergency
services.
With regard to deviating from the lock-in provisions of Medicaid
managed care regulations at 42 CFR part 438, we believe that the
disenrollment provisions of Sec. 438.56, which provide for a 90-day
period after initial enrollment in which a managed care enrollee may
change plans is consistent with the requirements of section 1932(a)(4)
of the Act and represents a reasonable time period for enrollees to
decide whether the plan in which they are enrolled will best meet their
needs. This trial period of enrollment is even more critical when the
plan is offering a benchmark or benchmark-equivalent benefit package.
We are not convinced that this limited period of time provides an
incentive for enrollees to plan-hop in order to access specific
benchmark benefits.
Further, CMS has specified three circumstances where cause for
disenrollment exists and permitted States to develop other reasons,
including but not limited to, the examples in Sec. 438.56(d)(iv).
Beyond these requirements, States have the flexibility to create
additional causes for disenrollment as best serves their beneficiaries
and the Medicaid Program.
Comment: Some commenters believed that CMS should require that all
non-managed care plans ensure adequate access to providers that accept
assignment of benefits and bill benchmark plans directly.
Response: Access standards apply to all aspects of the Medicaid
program, including benchmark and benchmark-equivalent plans. If States
choose to offer benchmark or benchmark-equivalent plans to Medicaid
beneficiaries, States must assure that access to providers and claims
payment are in compliance with current Federal regulations.
Comment: One commenter raised the potential problems of billing
alternate benefit insurers. The commenter believed CMS should ensure
that benchmark plan options should impose no additional administrative
burdens on participating Medicaid providers. Providers should not be
depended upon to refund payments and re-bill plans in the event that a
plan is billed for a Medicaid individual who is retroactively enrolled
into a different plan. Individual plan requirements should be
streamlined into the existing system to minimize complexity to the
already complex billing requirements.
Response: Provider billing procedures will vary among the States
based on the particular health care delivery system in the State at
issue. We do not anticipate that provider billing under an alternative
benefit program will necessarily differ from the way in which providers
currently bill for Medicaid services, or that providers will have to
establish new processes and systems to calculate, track, bill, and
report benchmark services. Moreover, because most States already offer
managed care enrollment, they already have experience ensuring
coordination of provider claims among different managed care entities.
Thus, we do not believe that the offering of alternate benefit packages
will impose significant administrative burdens on providers.
Comment: One commenter stated the regulation should require plan to
plan reconciliations of payment in instances where beneficiaries have
switched from one benefit plan to another, and in order to minimize
confusion about plan enrollment and benefits, benchmark plans should be
required to coordinate the receipt of beneficiary ID cards with the
beneficiary's effective date of enrollment.
Response: We acknowledge the commenter's concern regarding
coordination of beneficiary enrollment in a plan and reconciliation of
payment to providers. These are implementation and administrative
issues that are, at least initially, best addressed by the State. We
expect the State to appropriately coordinate enrollment and payment
processes in a fashion that minimizes confusion and we expect the State
to ameliorate coordination of payment issues so that providers are paid
appropriately and in a timely fashion. However, we believe that these
issues need not be addressed in regulation at this time, and that most
States already have systems in place to coordinate enrollment and
provider payments between managed care plans. Should there be evidence
of problems CMS will revisit this issue.
Comment: One commenter asserted that the final rule should require
States to provide an exceptions process in which beneficiaries can
obtain services not covered by a benchmark plan when they are medically
necessary, and to educate beneficiaries about how to pursue this
essential safeguard.
Similarly, States should also be required to provide hardship
exemptions if beneficiaries are unable to meet cost sharing
requirements in benchmark plans and should review each beneficiary's
eligibility category to ensure they meet statutory requirements for
assignment to benchmark plans.
Response: CMS agrees with the commenter that States should review
each beneficiary's eligibility category to ensure they meet statutory
requirements for assignment to benchmark plans. The requirements for
when mandatory enrollment can occur are outlined in Sec. 440.431 and
specify that only certain
[[Page 23079]]
groups of full benefit eligibles can be mandatorily enrolled in
benchmark benefit packages. We are requiring in Sec. 440.320 that
exempt individuals be fully informed regarding the choice for
enrollment in benchmark or benchmark-equivalent plans and that they
affirmatively enroll in benchmark and benchmark-equivalent plans. We
are also requiring that States comply with the Medicaid managed care
regulations including the information requirements for enrollees and
potential enrollees.
We are not requiring that States provide a process for
beneficiaries to obtain services not covered by a benchmark plan when
they are medically necessary, except with respect to children, because
such a process is not authorized by section 1937 of the Act. Benchmark
or benchmark-equivalent plans offered to beneficiaries constitute the
individual's medical assistance health care coverage. Children must be
provided access to the full range of EPSDT services, as defined in
section 1905(r). While section 1905(r) of the Act specifically requires
that States provide children necessary health care, diagnostic
services, treatment and other measures described in section 1905(a)
related to conditions discovered by a screening service, we believe
that any encounter with a health professional practicing within the
scope of his or her practice should be considered to be a screening
service for the purpose of the EPSDT requirement.
It is important to note that for those who voluntarily enroll in
benchmark or benchmark-equivalent plans, such individuals must be
permitted to revert to traditional Medicaid coverage at any time.
Requests by individuals to disenroll must be acted upon promptly.
Furthermore, we included at Sec. 440.320 a requirement for States to
have a process in place to ensure that any disenrollment request is
processed promptly and the individual is immediately able to access
services described in the standard Medicaid State plan while the State
is processing the individual's disenrollment request.
In terms of cost sharing, States are required to ensure that
benchmark or benchmark-equivalent plans comply with the cost-sharing
requirements at sections 1916 and 1916A of the Act, which includes the
provision that premiums and/or cost sharing not exceed 5 percent of the
family's income. Consistent with section 5006 of the ARRA, States are
required to ensure that eligible Indians are neither charged premiums
nor required to participate in cost sharing for services provided by
IHS providers or through contract health services through IHS
providers. The Act also provides that States may implement undue
hardship provisions for premiums and may permit providers to waive cost
sharing on a case-by-case basis.
Comment: One commenter believed alternative plans should include a
provision for mandatory cost sharing, where applicable, in return for
treatment or services. Uncollected cost-sharing places an unfair
financial burden on providers.
Response: States are required to ensure that benchmark or
benchmark-equivalent plans comply with the cost-sharing requirements at
sections 1916 and 1916A of the Act. These sections provide that States
can impose premiums and cost sharing on certain Medicaid beneficiaries,
and Section 1916A provides for enforcement of such premiums and cost
sharing on certain Medicaid beneficiaries (certain limitations do
apply). The enforcement of premiums and cost sharing through the denial
of medically necessary services is at a State's option. CMS is not
requiring that cost sharing be mandated in return for treatment or
services, since this would be inconsistent with the statutory language
provided by Congress in the DRA and could impose considerable hardship
and result in the denial of necessary health service for beneficiaries.
Comment: One commenter mentioned that because of the potential for
harm to beneficiaries, this rule should mandate strong requirements for
meaningful public input at both the Federal and State level when States
propose use of alternative benefit packages. Only a full open process
in which all stakeholders can participate will provide the thorough,
thoughtful analysis needed to determine whether specific changes will
foster genuine efficiency or threaten beneficiaries' access to
appropriate care.
These commenters noted that the State plan amendment process
provides almost no meaningful opportunity for public input. They noted
that States can implement changes the day after publishing a notice,
with no requirement to acknowledge or address comments.
The commenter suggested that meaningful opportunities for public
comment could include well-publicized and easily accessible public
hearings, ample opportunity for stakeholders to provide written
comments, and a requirement that State and Federal officials provide
written responses to comments.
Response: We agree that States must seek public input concerning
plans to offer alternative benefit packages. Thus, we are requiring in
Sec. 440.305 ``Scope'' that States secure public input prior to any
submission to CMS of a proposed State plan amendment that would provide
for an alternative benefit package. We are not requiring any specific
process to secure public input, in order to permit States flexibility
to design and use a public input process that meets State needs, but we
intend these processes to be meaningful and will be reviewing how they
are conducted to assure compliance with the law.
Comment: One commenter suggested that CMS require States to include
in Medicaid contracts with alternative benefit packages provisions that
require fair reimbursement for providers at rates no less than rates
paid under the traditional Medicaid program, including a reasonable
dispensing fee for pharmacy providers.
Further, the commenter believed that CMS should prohibit States
from procuring contracts that contain mail order prescription
requirements for Medicaid-eligible individuals. The commenter asserts
that Medicaid-eligible individuals who are required to enroll in
benchmark plans should have the option of receiving pharmacy services
in a retail pharmacy setting. CMS should also require that contracts
contain an assurance that allows extended quantities of medications
from retail pharmacies for Medicaid-eligible individuals receiving
treatment for chronic illnesses.
Response: States are required to submit State plan amendments to
establish rates and rate methodologies for all fee-for-service
institutional and non-institutional services as part of their approved
Medicaid State plan. Benchmark plans that utilize fee-for-service
delivery systems must follow the State plan reimbursement process. This
process is detailed at Sec. 447.200 and Sec. 447.201 and includes a
public notice requirement detailed at Sec. 447.205. We published
general rate setting regulations for drugs at 42 CFR part 447 subpart I
and for managed care entities at Sec. 438.6(c), and we expect States
to follow these rules when setting rates for benchmark and benchmark-
equivalent plans.
With regard to benchmark benefit plans that use managed care as the
delivery system, the requirements for actuarial soundness at part 438
apply in the same way they apply to any Medicaid managed care entity,
but we do not have statutory authority to review or approve
reimbursement rates to contracted providers under managed care
arrangements once the premium has been certified as actuarially
appropriate for the populations and
[[Page 23080]]
services in the contract. We do however, have the authority and
responsibility to review the provider network to determine that
individuals have adequate access to all medically necessary services.
With regard to mail order prescriptions, section 1937 did not
address or limit the use of mail order prescription requirements, or
otherwise address or limit the coverage of, or payment for,
prescription drugs.
Comment: One commenter recommended that CMS include in its rule an
evaluation of the impact on beneficiaries of the benchmark benefit
packages.
Response: CMS points the commenter to the ``Regulatory Impact
Analysis'' in section VI.B ``Anticipated Effects'' of this regulation.
D. 440.310 Applicability
Comment: One commenter disagreed that the medically needy
population should be exempt from participating in benchmark plans. The
commenter believed the rule should permit voluntary enrollment of
medically needy into benchmark plans in States such as Minnesota which
provide full benefits across the board to both categorically and
medically needy. Section 1937 of the Act only expressly prohibits
required participation by the medically needy but is silent as to
whether they can be voluntarily enrolled. It is illogical for CMS to
interpret Congressional intent to permit scaled back benefit coverage
for the categorically needy, while shielding the medically needy from
scaled back benefit packages.
Response: We agree with the commenter's suggestion that medically
needy populations may be offered voluntary enrollment in an alternative
benefit package. Thus, we revised the rule at Sec. 440.315 ``Exempt
Individuals'' to indicate that benchmark and benchmark-equivalent
benefits can be offered as a voluntary option to medically needy or
those eligible as a result of a reduction of countable income based on
costs incurred for medical care. We recognize that applying benchmark
benefit plans to medically needy individuals can be cumbersome
depending on the arrangements for benchmark coverage. If the State
administers its own benchmark benefit plan, enrolling and disenrolling
these individuals would be no more problematic than standard Medicaid
enrollment.
E. Section 440.315 Exempt Individuals
Comment: One commenter believed that these alternative benefit
packages should provide exemptions to additional Medicaid coverage
groups. Other commenters suggested that CMS use its discretion to
expand the categories of exempt individuals to include adults with
serious mental illness and children with serious emotional
disturbances.
Some commenters believed that all people with mental illness should
be exempt.
Response: The statute does not authorize CMS to exempt additional
categories of individuals from mandatory enrollment in alternate
benefit package. We have included the medically needy with the list of
exempt populations because the medically needy population is
effectively exempted from mandatory enrollment by exclusion from the
definition of ``full benefit eligible''.
We have defined ``medically frail'' and ``special medical needs''
individuals who are exempt from mandatory enrollment. At a minimum,
States must include children with serious emotional disturbances,
individuals with disabling mental disorders, individuals with serious
and complex medical conditions, and individuals with physical and or
mental disabilities that significantly prevent them from performing one
or more activities of daily living. Accordingly, we revised the
regulation at Sec. 440.315(f) to reflect this change. These are
minimum standards and States have the flexibility to expand this
definition.
Comment: One commenter requested a definition for exempt
individuals ``who qualify for Medicaid solely on the basis of
qualification under the State's TANF rules.'' The commenter noted that
no individual can qualify to receive Medicaid benefits solely on the
basis of their TANF eligibility, since TANF is not linked to Medicaid.
Response: In the proposed rule we published on February 22, 2008,
we stated that we interpreted the exemption from mandatory enrollment
in section 1937(a)(2)(B)(ix) of the Act to apply only to those
individuals who qualify for Medicaid because the State has elected to
link Medicaid eligibility to TANF eligibility. Under the law, since
passage of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (PRWORA), Medicaid eligibility is not tied
to TANF eligibility. While many States automatically enroll people
receiving TANF in Medicaid they do so because the design of the TANF
and Medicaid rules means that, in fact, all TANF individuals qualify
under the Medicaid rules. There is no direct eligibility link under
law, however, between TANF and Medicaid.
We have determined that our proposed regulation did not adequately
take into account the references in section 1937 to title IV-A, and
section 1931 of the Act. Section 1902(a)(10)(A)(i)(I) of the Act still
requires States to cover, in their Medicaid programs, individuals
receiving cash assistance under part A of title IV. However, section
1931 of the Act provides the rules for determining whether an
individual is treated as a recipient of title IV-A assistance for
purposes of Medicaid eligibility. Under section 1931 of the Act,
references to title IV-A must be considered to be references to the IV-
A State plan that was in effect prior to the date that title I of
PRWORA took effect. In other words, the AFDC cash assistance rules are
carried over to Medicaid eligibility under section 1931, (States may
adopt less restrictive rules under section 1931(b)(2) of the Act), but
actual eligibility for or receipt of cash assistance is not a
requirement under section 1931. Accordingly, we are revising our
regulation at Sec. 440.315(i) to provide that parents or caretakers
who qualify for medical assistance on the basis of eligibility to
receive assistance under a State plan funded under part A of title IV,
as determined under section 1931 of the Act, are exempt from the
requirement to enroll in benchmark or benchmark-equivalent coverage.
These are the parents who, at a minimum, States must cover under
section 1931. We are also clarifying that we interpret the reference to
``parents'' in section 1937(a)(2)(B)(ix) to include caretakers, as
defined in section 1931. We are not requiring that parents or
caregivers who qualify for Medicaid on the basis of more liberal income
or resource methodologies which a State uses pursuant to the option
available under section 1931(b)(2)(C) be exempt from mandatory
enrollment in benchmark or benchmark-benefit plans, although States
may, at their option, exempt some or all such individuals.
Comment: A commenter stated the proposed rule defines the exempt
``special medical needs'' group to include two of the three groups that
are also exempt from mandatory enrollment in managed care plans under
section 1932(a)(2) of the Act: ``Dual eligibles'' and certain children.
However, the proposed rule does not exempt the third group that is
exempt from mandatory enrollment in managed care plans, American
Indians/Alaska Natives. Several commenters believed that the same
compelling policy reasons for excluding American Indians/Alaska Natives
from mandatory managed care
[[Page 23081]]
support excluding them from mandatory enrollment in benchmark plans,
and requested that we revise the rule to be consistent with current
policy described in the Medicaid managed care rule of 2002.
Response: In the proposed rule we mistakenly confused two distinct
groups in our definition of ``individuals with special needs'' and
included individuals eligible for Medicare as a special needs
population when it is identified in section 1937 as a separate exempt
population. We have therefore deleted that reference. Section
1937(a)(2)(iii) of the Act exempts individuals entitled to Medicare
benefits (dual eligibles), regardless of medical need, from mandatory
enrollment in an alternative benefit package. There is a separate
statutorily exempt category at section 1937(a)(2)(vi) of the Act for
individuals who are medically frail or have special medical needs. This
final regulation includes both of these groups separately.
Specifically, in the proposed rule, we specified that ``individuals
with special needs'' means the populations identified in Sec.
438.50(d)(1) and Sec. 438.50(d)(3). The reference to Sec.
438.50(d)(1) was an erroneous reference to the dual eligible population
discussed above. The reference to Sec. 438.50(d)(3) was made because
that population was a pre-existing definition of the statutory term
``children with special medical needs'' contained at section
1932(a)(2)(A) of the Act. We did not include a separate definition of
adults with special medical needs in the proposed rule.
After reviewing public comment, we have determined that States
should be allowed flexibility to adopt reasonable definitions of
``individuals with special medical needs'' as long as that definition
includes, at a minimum, the children specified in Sec. 438.50(d)(3),
children with serious emotional disturbances, individuals with
disabling mental disorders, individuals with serious and complex
medical conditions and individuals with physical, and/or mental
disabilities that significantly impair their ability to perform one or
more activities of daily living.
We recognize that Congress included special protections for
American Indians under the managed care provisions at section
1932(a)(2)(C) of the Act, but those special protections were not
included under section 1937 of the Act. It is possible that the managed
care protections were based on the fact that American Indians have
access to the IHS and tribal health care delivery system, and there was
concern about mandating enrollment in a managed care plan that would
not be consistent with that health care delivery system.
While American Indians/Alaska Natives are not a statutory group
that is exempt from enrollment in an alternative benefit package, they
remain exempt from mandatory enrollment in managed care when such an
option is utilized under section 1932 of the Act. As a result, a State
that operates an alternative benefit package through managed care
providers must provide American Indians/Alaska Natives with a health
care delivery system that is consistent with the special protections
related to managed care enrollment contained in section 1932(a)(2)(C)
of the Act as well as section 1932(h) of the Act, added by ARRA, that
addresses the requirement that American Indians/Alaska Natives enrolled
in managed care have access to IHS providers.
Comment: One commenter believed that States may be discouraged from
pursuing the benchmark option because of the extra work required for
determining eligibility, along with the fact that potential savings may
be limited. The commenter asked that CMS not impose any additional
definition of sub-groups that must be identified and carved out of
benchmark plans.
Response: The benchmark benefit is an option that States may elect
to utilize within their Medicaid State plan when the State determines
its value for a defined population. The additional steps needed in
determining eligibility are necessary to assure that the benefit plan
is targeted appropriately. The ultimate value of a benchmark benefit
plan to both the State and beneficiaries is dependent upon the clear
definition of eligibility for the defined benefit package. The exempt
categories were established by statute and must be evaluated as a
condition of providing a benchmark or benchmark-equivalent benefit.
Comment: One commenter asked for additional clarification of the
phrase ``or being treated as being blind or disabled'' in Sec. 440.315
of this regulation.
Response: This phrase needs to be interpreted in light of the
particular eligibility conditions in that State. For example, the
phrase could refer to States that qualify under section 209(b) of the
Act, since States with this classification can have a more restrictive
definition of blindness or disability. The term could also refer to one
of the working disabled groups, since one group has a categorical
requirement that the person have a medically determinable severe
impairment, which does not exactly match the criteria for a
determination of ``disabled.'' Additionally, Territories operate on a
different definition of blindness and disability than the 50 States.
Comment: Some commenters stated that the proposed rule exempts from
mandatory enrollment the ``medically frail.'' Several commenters
suggested this term be given specific meaning in the rule. They
suggested it include anyone who is eligible for or is receiving
Medicare or Medicaid services for home health, hospice, personal care,
rehabilitation or home and community-based waivers, or who is at
imminent risk of need for these types of services.
Another commenter suggested this group be defined as individuals
with multiple medical conditions and/or a chronic illness.
Response: After considering public comment on the issue, we have
included in the text at Sec. 440.315(f) guidance on how States must,
at a minimum, define ``medically frail.'' Additionally, we will require
that States offering alternative benefit packages inform CMS as to
their definition of ``medically frail.'' States will be required to
include information regarding which population groups will be
mandatorily enrolled in the benchmark program and will need to ensure
that enrollment is optional for exempt populations, including
individuals defined by the State as ``medically frail.'' Additionally,
the required public input process should include informing interested
parties of the State's proposed definition of ``medically frail.''
Comment: Another commenter suggested CMS use the existing
definition of children with special health care needs which is defined
by the Department of Health and Human Services, Health Resources and
Services Administration, Maternal and Child Health Bureau (MCHB) as:
``Children with special health care needs:'' ``Children who have or are
at increased risk for a chronic physical, developmental, behavioral, or
emotional condition and who also require health and related services of
a type or amount beyond that required by children generally.''
Other commenters believed the definition of ``special medical needs
individuals'' should include adults who meet the Federal definition of
an individual with serious mental illness and children who meet the
Federal definition of children with serious emotional disturbance, as
promulgated by the Substance Abuse and Mental Health Services
Administration (SAMHSA). The SAMHSA definition would include some
individuals who, for one reason or another, are not eligible as persons
with a disability, but
[[Page 23082]]
nevertheless are significantly impaired by their mental disorder.
Response: In the February 22, 2008 proposed rule, we defined
``individuals with special medical needs'' to be consistent with Sec.
438.50(d)(3), which implements and interprets the term ``children with
special medical needs'' used in section 1932(a)(2)(A) of the Act. This
definition refers to children under age 19 who are eligible for SSI,
section 1902(e)(3) of the Act, TEFRA children, children in foster care
or receiving other out of home placement, children receiving foster
care or adoption assistance services or who are receiving services
through a community based coordinated care system.
We appreciate commenters' suggestions of additional populations of
children and adults for inclusion in the definition of special medical
needs. In this final rule, we are allowing States the flexibility to
adopt a reasonable definition of the term ``special medical needs'' and
we expect States to consider, at a minimum, all of these individuals
for inclusion in the definition of ``individuals with special medical
needs.''
To maintain State flexibility, we have provided guidance to States
in our discussion of these terms and in the regulation at Sec.
440.315(f) and we are requiring that the exempt population include, at
a minimum, those children identified in Sec. 438.50(d)(3), children
with serious emotional disturbances, individuals with disabling mental
disorders, individuals with serious and complex medical conditions and
individuals with physical and or mental disabilities that significantly
impair their ability to perform one or more activities of daily living.
Also, as stated previously, CMS will require that States offering
alternative benefit packages inform CMS as to their definition of
``medically frail'' and ``special medical needs.'' States will be
required to ensure that exempt populations, including individuals with
``special medical needs'' or who are ``medically frail'' are not
mandatorily enrolled in alternative benefit packages, but are instead
offered an informed choice. Additionally, CMS will interpret the
required public input process to include informing interested parties
as to the proposed definition of ``special medical needs.''
F. Section 440.320 State Plan Requirements--Optional Enrollment for
Exempt Individuals
Comment: One commenter supported our regulation at Sec. 440.320
and appreciated the willingness of CMS to provide for optional
enrollment of otherwise exempt individuals. Several other commenters
urged CMS to require States to provide more information and assistance
to exempt individuals who are given the option to enroll in alternative
coverage.
Response: We agree with the commenter that if States plan to offer
enrollment in a benchmark plan to exempt individuals, the State must
provide information and assistance to exempt individuals or their legal
guardians/caregivers who are given the option to enroll in alternative
coverage plans so they can make an informed choice. We proposed in
Sec. 440.320 that States must inform the individuals that enrollment
is voluntary and that the individual may disenroll from the benchmark
or benchmark-equivalent benefit package at any time and regain
immediate access to the standard full Medicaid program under the State
plan while the State processes their disenrollment request. We also
proposed that States must inform the individual of the benefits
available under the benchmark or benchmark-equivalent benefit package
and provide a comparison of how the benefits, and if relevant, the cost
share differ from the benefits and cost share available under the
standard full Medicaid program. We also required that the State
document in the individual's eligibility file that the individual was
informed and voluntarily chose to enroll in the benchmark or benchmark-
equivalent benefit package.
After considering public concerns as to the importance of the
informed choice process, we revised the regulation at Sec. 440.320(a)
to require the State to effectively inform exempt individuals about the
voluntary nature of their enrollment, and that they may choose to
disenroll at any time from the benchmark or benchmark-equivalent plan
in order to have immediate and full access to the standard Medicaid
benefits, the benefits available under the benchmark benefit plan, the
cost associated with the benchmark benefit plan, and to provide a
comparison between the benefits available under the benchmark benefit
plan and cost share, to the benefits and cost share provided by the
standard, full Medicaid program. To support these requirements we have
also included the requirement that the State document in the
individual's eligibility file that the individual elected to enroll in
the benchmark plan after receiving such information regarding benefits
and disenrollment rights.
As part of the State Plan Amendment (SPA) approval process whereby
States receive approval from CMS to implement new benefits under their
State plan, States must define their disenrollment process and include
a specific time period for disenrolling a beneficiary and assuring full
access to standard Medicaid coverage. To the extent that the informed
choice process continues to raise concerns, we will consider the
development of additional guidance as to what processes are necessary
to insure that the informed choice process is effective.
Comment: One commenter said that ``exempt'' populations should not
be allowed to enroll in an alternative benefit plan at all.
Response: The statute states that exempt individuals may not be
required to enroll in an alternative benefit plan, and with the
protections noted, it is reasonable to give such individuals the
opportunity to enroll in such plans. Alternative benefit plans may in
fact have richer benefits than traditional State plan services and be
targeted to the specific needs of exempt individuals. We are aware,
however, that the benchmark plan may not provide all the services as
the traditional plan and that exempt groups should not in any way be
enrolled in such plans involuntarily, or without full knowledge of the
consequences. Accordingly, this regulation provides new protections to
assure that exempted individuals are fully informed about their options
for enrolling and disenrolling from an alternative benefit plan.
Comment: One commenter believed the proposed rule was silent on the
requirement that the State provide information in plain language that
is understood by the individual, parent, or guardian including clear
instructions on how to access EPSDT services not provided by the
benchmark plan and how to disenroll from the benchmark plan. One
commenter suggested that CMS establish literacy and translation
standards for benefit information sheets and another commenter
requested that at a minimum, information should be provided in the
beneficiary's spoken language and at an appropriate reading level.
Response: We agree that it is important to provide information in
plain language and individuals should be provided clear instructions on
how to access EPSDT services not provided by benchmark plans.
Furthermore, individuals should also receive information on how to
disenroll from benchmark plans. We are requiring in Sec. 440.320 that
States effectively inform exempt individuals of the choice, and provide
sufficient information in order to make an informed choice, including a
comparison of benefits and any cost
[[Page 23083]]
sharing. Exempt individuals must be afforded the opportunity to
disenroll from benchmark or benchmark-equivalent coverage promptly and
without any loss of access to the full standard Medicaid benefits, if
they determine that the coverage is not meeting their health care
needs.
Comment: Some commenters stated that the rules should provide for
immediate revocation of any voluntary election at the discretion of
those exempt individuals who elect an alternative plan. These
commenters urged that revocation be permitted through telephone, in
writing, in person, by electronic communication, or by a designee, so
as to make revocation as simple as possible and as quick as possible
for beneficiaries. The commenters also asserted that the State should
be required to provide immediate notification to such individuals of
the right to revoke their election if they fall into an excluded
category. The commenters urged that coverage and payment should not be
interrupted during changes in election and marketing should not be
permitted by alternate plans to excluded groups.
These commenters asked that the disenrollment process from
benchmark plans allow a seamless transition to and from the selected
program and minimize the administrative burden on the provider while
ensuring care delivery is not interrupted.
Response: We agree that coverage and payment should not be
interrupted during changes in election. It is important that
coordination of care continue during any time of transition either from
one Medicaid eligibility group to another or from one benefit program
to another. Thus, in considering the commenters' suggestions, we have
provided in Sec. 440.320 that, for individuals who voluntarily enroll
and later determine they want to return to traditional Medicaid and/or
for individuals who are later determined eligible for an exempted
group, disenrollment requests must be acted upon promptly and States
must have a process in place to ensure full access to standard Medicaid
State plan services while disenrollment requests are being processed.
Furthermore, we expect that for individuals who voluntarily enroll and
later decide to return to traditional Medicaid and/or for individuals
who are later determined eligible for an exempted group, the State will
process disenrollment requests consistent with the managed care
regulations at Sec. 438.56(e), and the effective date of disenrollment
must be no later than the first day of the second month following the
month in which the enrollee files the request.
Comment: Some commenters recommended that CMS enhance the proposed
rule to include a section on CMS oversight containing a requirement
that CMS approve State informational materials that provide comparative
information and information on choice. Other commenters were concerned
that inappropriate marketing activities such as those they believe are
being used by some Medicare Advantage plans, may be adopted by
benchmark plans. These commenters urged CMS to be aware of the
potential for inappropriate marketing tactics, require States to
oversee marketing activities, and impose limits on marketing to ensure
individuals are not enrolled under false pretenses.
Response: To the extent that benchmark and benchmark-equivalent
benefit packages are provided through managed care plans, States must
comply with the Medicaid managed care rules at 42 CFR part 438.
Marketing requirements for managed care plans are described in Sec.
438.104. States must consider these requirements in contracting with
these entities.
We will monitor implementation to determine if additional measures
are needed.
Comment: Other commenters indicated that CMS should require strong
beneficiary protections for people, including frail older and disabled
beneficiaries, who have the opportunity to voluntarily enroll in
benchmark plans. The commenters indicated that these protections should
include objective counseling to make sure they understand the potential
for higher costs and make truly informed decisions, a ban on aggressive
and coercive marketing such as door-to-door sales, a requirement to
document network adequacy for additional populations, and ongoing
monitoring to ensure that these beneficiaries are getting the care they
need. Some commenters indicated that, even with full information,
individuals who voluntarily enroll may be likely to make an
inappropriate election. They suggested a professional counselor
independent of the plan be available to review their plan selection.
Response: We believe a professional counselor or enrollment broker
would be a reasonable administrative protection that could be adopted
by a State, but we are not requiring it. This is an operational issue
that may depend on the circumstances of a particular State's program.
States who contract with an enrollment broker can receive
administrative match from CMS at the 50 percent match rate. To the
extent that the State offers alternative benefits through managed care
plans, enrollment brokers must operate consistently with the
requirements at Sec. 438.810. Consistent with the managed care rules
at Sec. 438.10, States are encouraged to provide information at least
annually as to an individual's enrollment choice under the benchmark
option or the traditional State plan option. This could be accomplished
at the point of re-determining eligibility for enrollees.
Additionally, if a change in eligibility status has occurred (for
example, non-pregnant female mandatorily enrolled in the benchmark plan
becomes pregnant and is no longer eligible for mandatory enrollment),
the State will have to provide such individuals with information about
their benefit options as soon as the State becomes aware of the change
in eligibility. If the individual chooses to disenroll, the individual
must have full access to standard Medicaid State plan services that may
not be available in the benchmark plan while the State implements the
disenrollment process.
Comment: Several commenters believed exempt individuals will be
automatically enrolled without their expressed consent and wanted an
assurance that this will not occur. These commenters urged CMS to
safeguard exempt individuals from being enrolled in benchmark or
benchmark-equivalent plans without their prior informed consent by more
expressly prohibiting States from taking an automatic enrollment or
default enrollment approach to their enrollment. They suggested that
the proposed language could allow or even encourage States to adopt an
automatic or default enrollment approach without further clarification
because the language could be read to allow States to initially enroll
all exempt persons who do not affirmatively choose not to enroll. These
commenters indicated that failure to clarify this point would be
construed as approval of opt-out practices and would not protect
against any form of automatic or ``presumed voluntary'' enrollment.
Response: Section 1937 of the Act provides that exempt individuals
cannot be mandatorily enrolled in benchmark or benchmark-equivalent
plans. We proposed to permit States to offer exempt individuals a
voluntary option to enroll, based on informed choice. In order for
exempt individuals not to be mandatorily enrolled and to have made an
``informed choice'' about enrollment, the choice must take place before
enrollment in the benchmark or benchmark-equivalent plan. We have
[[Page 23084]]
amended the final rule to make this clear and to require the State to
inform the exempt individual of the benefits available under the
benchmark or benchmark-equivalent package and the cost of such a
package. Furthermore, these actions should occur before the receipt of
services in a benchmark or benchmark-equivalent plan. We mentioned
earlier that we require that the individual's file be documented to
reflect that an exempt individual is fully informed and has chosen to
be enrolled in a benchmark or benchmark-equivalent plan. CMS, in
response to these comments, has made it clear that individuals cannot
be enrolled until an informed election is made.
In terms of CMS monitoring, we provide in Federal regulations at
Sec. 430.32 for program reviews of State and local administration of
the Medicaid program. In order to determine whether the State is
complying with the Federal requirements and the provisions of its
Medicaid plan, we may conduct reviews that include analysis of the
State's policies and procedures, on-site review of selected aspects of
agency operation, and examination of individual case records. We also
require in Sec. 440.320 that the State track and maintain the total
number of individuals that have voluntarily enrolled in a benchmark
benefit plan and the total number of individuals that have elected to
disenroll from the benchmark benefit plan.
Comment: One commenter believed that the rule should describe the
level of detail required in the State's description of the difference
between State Plan benefits and benchmark-equivalent plan benefits
because the commenter believed it is important that there be a
detailed, written comparison.
Response: We agree with the commenter on the importance of the
benefit comparison. We have required that if the State chooses to offer
benchmark or benchmark-equivalent benefit options to individuals exempt
from mandatory enrollment such individuals must be given, prior to
benchmark enrollment, a comparison of traditional State plan benefits
and the benefits offered in the benchmark or benchmark-equivalent
benefit package, as well as any differences in cost sharing. In order
for exempt individuals to make an informed choice, the information must
be fully detailed by the State in a format that is understandable by
the beneficiary.
Comment: A commenter believed CMS should prohibit States from
implementing procedures that make it more difficult for beneficiaries
to stay in the regular Medicaid program than to enroll in benchmark
benefit plans. Beneficiaries should not be asked to make a choice
without being afforded a reasonable time to evaluate the options.
Another commenter was concerned that a State could reduce its standard
Medicaid State plan services in order to force exempt beneficiaries to
enroll in a benchmark or benchmark-equivalent plan.
Response: We agree that individuals should be given a reasonable
time to evaluate the options in considering traditional Medicaid
benefits versus benchmark or benchmark-equivalent options. In order for
individuals to make an informed choice, individuals must have ample
time to consider the options available. Therefore, we have revised the
regulatory provision at Sec. 440.320(a)(3) to require that the State
document that the individual had ample time for an informed choice. We
are not prescribing standards for what constitutes ``ample time''
because we believe this may vary based on the circumstances and/or
individual involved. With regard to States reducing their standard
Medicaid State plan services, section 1937 of the Act does not change
State flexibility to reduce or add optional 1905(a) medical services.
However, if such changes are done for the purpose of coercing exempt
individuals to enroll in benchmark plans, such action may not be
consistent with the requirement that exempt individuals must be
permitted to make a fully voluntary decision to enroll in a benchmark
plan.
Comment: Another commenter believed CMS should require States to
institute expedited processes to transition out of benchmark plans
those individuals who become eligible for exempted categories.
Response: We agree with the commenter that States should provide
for timely transition of individuals if they become eligible for exempt
categories and thus are not required to be mandatorily enrolled in a
benchmark plan. Congress clearly identified individuals who are exempt
from mandatory enrollment in benchmark or benchmark-equivalent plans.
As mentioned previously, we have revised the final rule at Sec.
440.320 to require that States inform exempt individuals that they may
disenroll at any time and provide them with information about the
disenrollment process. We have also revised Sec. 440.320 to require
that disenrollment requests be acted upon promptly and that States have
a process in place to ensure full access to standard Medicaid State
plan services while any disenrollment requests are being processed. We
further revised Sec. 440.320 to include a requirement for States to
maintain data that tracks the number of voluntary enrollments in
benchmark and benchmark-equivalent benefit plans and the number of
disenrollments from these plans.
These requirements also apply to individuals who become part of an
exempt population for which no mandatory enrollment can occur. It is
incumbent upon the State to ensure that procedures are in place to
notify these individuals of their change in status and to provide them
with information explaining their right to disenroll from the benchmark
or benchmark-equivalent benefit plan and return to the traditional
Medicaid State plan. We believe that States should not rely on the
individual's ability to recognize that their change in status permits
them to revert back to traditional Medicaid and that they are entitled
to the full range of Medicaid benefits. It is therefore the
responsibility of the State to assure that these individuals have the
choice to receive benchmark plan benefits, or the benefits available
under the traditional Medicaid State plan.
Comment: One commenter asked for clarification on whether the
benchmark or benchmark-equivalent benefit packages would apply to
``unqualified individuals'' who fall under the ``exempt category'' and
who could be offered optional enrollment in a benchmark benefit
package.
Response: We wish to clarify that unqualified individuals (aliens
who are not lawfully admitted for permanent residence in the United
States or otherwise do not meet the Medicaid eligibility requirements
for aliens) for example, aliens who are residing in the U.S. illegally,
are exempt individuals who cannot be mandatorily enrolled in benchmark
plans because in most cases they are only eligible for emergency
services under Medicaid.
Unqualified or undocumented individuals who are otherwise eligible
for Medicaid (for example, meet income or residency requirements) are
only covered for emergency medical services under section 1903(v) of
the Act. Generally, the determination that such an individual has
received an emergency medical service is made retrospectively by the
State. Therefore, it is unlikely that a State would decide to offer the
benchmark or benchmark-equivalent benefit option for these individuals,
even if enrollment were voluntary.
[[Page 23085]]
G. Section 440.330 Benchmark Health Benefits Coverage
Comment: A few commenters questioned the coverage standards of a
Secretary approved benefit package. They contended that under this
option, CMS could approve coverage of any kind, one that may include or
exclude any benefits the State chooses. They asserted that this failure
to recognize any minimum set of required benefits in Medicaid could
limit access to critical health care services. They argued that
allowing States even greater flexibility, by not requiring that
coverage meet benchmark levels, is inappropriate and is likely to
result in more beneficiaries going without health care services until
they become sick and require emergency treatment.
Another commenter agreed and stated that the proposed rule says,
``Secretary-approved coverage is any other health benefits coverage
that the Secretary determines * * * provides appropriate coverage for
the population proposed to be provided this coverage.'' The commenter
finds this statement troublesome. This provision gives the Secretary
the wide discretion to approve a number of plans that are more flexible
than the benchmark plan requirements as articulated in this rule. This
provision would give States the option to craft qualifying plans that
include or exclude any benefits that the State chooses.
The commenters urged CMS to remove this fourth option for
Secretary-approved benchmark packages from the proposed rule.
Response: The statute provides States with the option of Secretary-
approved coverage, and we believe we have provided for sufficient
protections to ensure that this option will be consistent with the
statutory purpose of meaningful health benefits coverage while also
allowing State flexibility. In this final rule, we have articulated the
general standard that Secretary-approved coverage must be appropriate
coverage to meet the needs of the population provided that coverage.
The regulations also provide a number of documentation requirements so
that CMS can determine that this standard has been met. States are
required to submit a full description of the proposed coverage. The
State must include a benefit-by-benefit comparison of the proposed plan
to one or more of the three benchmark plans specified in Sec. 440.330
or to the State's standard full Medicaid coverage package under section
1905(a) of the Act, as well as a full description of the population
that would receive the coverage. Additionally, States will be providing
to CMS any other information that would be relevant in making a
determination that the proposed coverage would be appropriate for the
proposed population. In considering Secretary-approved coverage, we
will review individual State designs on a case-by-case basis. To the
extent that State designs deviate from the other options for benchmark
coverage (for example, State employees coverage, etc.) or traditional
Medicaid State plan coverage, we will consider the information provided
as a result of the public input process and any other information
States submit that would be relevant to a determination that the
proposed coverage would be appropriate for the proposed population.
We believe that Secretary-approved coverage can be appropriate to
meet the needs of the targeted population provided that coverage. To
date, the majority of the approved benchmark plans are Secretary-
approved benchmark plans and most of these include not only all regular
Medicaid State plan services but provide for additional services like
disease management and/or preventive services.
Comment: Some commenters believed that to allow States to establish
alternative health benefit programs that do not include family planning
services is counter-productive to ensuring the health of Americans and
maintaining the sustainability of the Medicaid program. Also, a
benchmark or benchmark-equivalent plan would not be appropriate for
individuals of childbearing age if it did not include access to family
planning services. The commenter believed that no health benefits
package would be ``appropriate'' for individuals of childbearing age if
it did not include access to family planning services and supplies, and
asked CMS to revise the proposed rule to clarify that, in order to be
considered ``appropriate,'' a benchmark or benchmark-equivalent plan
must include coverage of family planning services and supplies.
The commenter also urged CMS to amend the rule to allow
beneficiaries to disenroll from any such alternative benefit plan and
reenroll in traditional Medicaid if the plan does not cover family
planning services and supplies.
Several commenters noted that family planning is basic preventive
health care for women and that ensuring a woman's freedom of choice is
critical in the delivery of these services. The commenters stated that
birth control, the main component of family planning coverage, is the
most effective way to: (1) Prevent unwanted pregnancies, (2) safely
space pregnancies in the interest of the mother and child's health, and
(3) keep women in the workforce. Furthermore, the commenters believed
that birth control enables preventive behaviors and allows for the
early detection of disease by getting women into doctor's offices for
regular health screenings.
One commenter believed that the legislation authorizes the
Secretary to approve benchmark plans that provide ``appropriate
coverage for the population proposed to be provided that coverage.''
Similarly, the legislation requires benchmark-equivalent coverage to
include ``other appropriate preventive services, as designated by the
Secretary.'' Coverage offered to women of reproductive age cannot be
considered ``appropriate'' if it excludes coverage of family planning
services and supplies.
Some commenters asserted that permitting some plans to exclude
coverage of family planning runs directly counter to three of the major
goals articulated by the legislation's supporters: reducing Medicaid
costs, promoting personal responsibility and improving enrollees'
health.
Other commenters believed that approximately half of all
pregnancies in the United States are unplanned and there is a strong
correlation between unintended pregnancies and failure to obtain timely
prenatal care. They stated that guaranteeing coverage of family
planning services for women enrolled in Medicaid benchmark plans
increases the likelihood that these women will be under the care of a
health professional before pregnancy, and that when they do become
pregnant they will obtain timely prenatal care as recommended by the
American College of Obstetricians and Gynecologists.
The commenters urged the Department to revise Sec. 440.330 to
clarify that in order for Secretary-approved coverage to be considered
appropriate coverage for women of reproductive age, it must include
family planning services and supplies. In addition, the commenters
urged the Department to modify Sec. 440.335 to designate family
planning services and supplies as a required preventive service that
must be included in all benchmark-equivalent plans offered to women of
reproductive age.
Response: If one of the statutorily-specified benchmark packages
(that is, FEHB, State Employees plan, and commercial HMO plan) did not
contain family planning services and supplies, the statute permitted
States to base an alternative benefit package on that
[[Page 23086]]
specific benchmark plan. CMS had no authority to disapprove the use of
a statutorily-specified benchmark plan as the basis for an alternative
benefit package. However, at the time that this regulation was being
revised the Patient Protection and Affordable Care Act (PPACA), (Pub.
L. 111-148), had not yet been enacted. That law has now amended section
1937(b) of the Act to add additional requirements affecting benchmark
and benchmark-equivalent coverage, including the requirements for
coverage of family planning services and supplies. We intend to issue a
second final rule implementing the changes made by PPACA with a
shortened effective date to bring the provisions of this regulation
into conformity with the statute.
Consequently, we are revising Sec. 440.375 to update the title and
revise the regulation at this section to indicate that States can
provide benchmark or benchmark-equivalent coverage to individuals
without regard to the requirements relating to the scope of coverage
that would otherwise apply under traditional Medicaid benefit packages.
The scope of coverage would still need to be consistent with the
requirements for the scope of coverage contained in this subpart, which
are based on the statutory benchmark or benchmark-equivalent coverage
provisions.
With respect to Secretary-approved coverage, we agree with the
commenters that if such a benchmark benefit plan is provided to
individuals of child bearing age that does not include family planning
services and supplies, it would not be appropriate to meet the needs of
the population it serves and would have to therefore include these
services. Additionally, if a non-Secretary approved benchmark plan such
as a commercial HMO plan does not include family planning services and
supplies, States have the option of adding family planning services to
the benchmark, at the enhanced FMAP rate established for these
services.
With respect to benchmark-equivalent coverage in Sec. 440.335, we
have added family planning services and supplies as required services.
In addition we have added emergency services as other required
appropriate preventive services designated by the Secretary, consistent
with the strong emphases the Medicaid statute places on these
preventive services.
Comment: Other commenters believed that one reason States may wish
to design a plan under the option for benchmark-equivalent or
Secretary-approved plans is to offer beneficiaries important services
that are not otherwise covered by Medicaid or a standard benchmark
plan. The commenters stated that this rule does not permit this. CMS
should allow States to submit proposals that include other services and
judge the overall plan proposed by the State to assess its efficiency.
Response: Section 1937 provides that benchmark-equivalent or
Secretary-approved plans can be offered as benchmark plans, so long as
the identified basic services are provided as part of the benchmark-
equivalent benefits and the benefit package is appropriate to meet the
needs of the population it serves for Secretary-approved coverage. The
rule is consistent with the statute. The rule provides that the scope
of a Secretary approved health benefits package or any additional
benefits will be limited to benefits within the scope of the categories
available under a benchmark coverage package or the standard full
Medicaid coverage under section 1905(a) of the Act. This provision
allows States flexibility to offer additional health care services that
would not otherwise be offered. Additional services are limited to
those in categories offered under a benchmark plan or section 1905(a)
of the Act because section 1937 of the Act did not expressly authorize
coverage beyond the defined scope of medical assistance, and these
limits ensure that additional services will be of the type generally
considered as health care services.
H. Section 440.335 Benchmark-Equivalent Health Benefits Coverage
Comment: One commenter urged CMS to clarify that plans cannot use
actuarial methods that further reduce benefits because of cost-sharing
limits.
Another commenter noted that the preamble of the proposed rule
indicates that even if the benchmark plan has 50 percent coinsurance,
the State would have to ensure that cost sharing does not exceed the
applicable limits in Medicaid, which are substantially lower.
However, Sec. 440.340 specifies that the actuarial report ``should
also state if the analysis took into account the state's ability to
reduce benefits because of the increase in actuarial value of health
benefits coverage offered under the State plan that results from the
limitations on cost sharing * * * under that coverage.'' The commenter
strongly urged CMS to clarify that this language does not allow States
to reduce mental health benefits below 75 percent of the value of the
benchmark benefits because there are lower co-payments in the
benchmark-equivalent plan. Congress intended that individuals would get
75 percent of the value of the benefit; they did not intend to reduce
the value of this benefit through cost-sharing limitations.
Response: We agree that clarification is needed in terms of using
actuarial methods to further reduce benefits because of cost-sharing
limits. We have specified in Sec. 440.340 that, as a condition of
approval of benchmark-equivalent coverage, States must provide an
actuarial report with an actuarial opinion that the benchmark-
equivalent coverage meets the actuarial requirements for coverage
specified in Sec. 440.335. We have also specified in Sec. 440.340
that the actuarial report must--
Be prepared by a member of the American Academy of
Actuaries and must meet the standards of this Academy;
Use generally accepted actuarial principles and
methodologies of the Academy, standard utilization and price factors,
and a standardized population representative of the population
involved;
Use the same principles and factors in analyzing the value
of different coverage (or categories of services) without taking into
account differences in coverage based on the method of delivery or
means of cost control or utilization use;
Indicate if the analysis took into account the state's
ability to reduce benefits because of the increase in actuarial value
of health benefits coverage offered under the State plan that results
from the limitations on cost sharing under that coverage;
Select and specify the standardized set of utilization and
pricing factors as well as the standardized population; and
Provide sufficient detail to explain the basis of the
methodologies used to estimate the actuarial value.
In considering the actuarial value, we expect that the States and
the actuaries making the determination of actuarial equivalence will
account for changes in cost sharing between the benchmark-equivalent
plan and the benchmark plan as well as account for any differences in
income and assets between Medicaid beneficiaries and the enrollees in
the benchmark plan. Cost sharing for the Medicaid benchmark-equivalent
plan is still subject to the limitations set forth in this rule and in
sections 1916 and 1916A of the Act. The determination of actuarial
equivalence should provide an aggregate actuarial value that is at
least equal to the value of one of the benchmark benefit packages, or
if prescription drugs, mental health services, vision and/or hearing
services
[[Page 23087]]
are included in the benchmark plan, an aggregate actuarial value that
is at least 75 percent of the actuarial value of prescription drugs,
mental health services, vision and/or hearing services of one of the
benchmark benefit packages. Changes to the benchmark-equivalent plans,
including changes in the cost-sharing structure that would result in
expected benefit amounts less than under the benchmark plan or less
than 75 percent of the actuarial value of prescription drugs, mental
health services, vision and/or hearing services, would not be allowed
under this rule.
Comment: Several commenters note that the standard for adopting a
benchmark-equivalent coverage package is set at 75 percent of the
actuarial value of that category of services in the benchmark plan and
wants to understand if the percentage is set in statute. The commenters
believe that if this percentage is not a statutory provision, it would
be important to describe the basis for this standard.
Response: The DRA provides for this standard. Section 1937(b)(2)(C)
of the Act specifies that the benchmark-equivalent coverage with
respect to prescription drugs, mental health services, vision services,
and/or hearing services must have an actuarial value equal to at least
75 percent of the actuarial value of the coverage of that category of
services in the benchmark plan. We have maintained this standard in the
rule consistent with the statutory provision.
Comment: One commenter requested that benchmark-equivalent plans be
required to provide the full continuum of care including the care
required by individuals with cancer.
Another commenter pointed out that the benchmark-equivalent plans
are allowed to provide 75 percent of the actuarial value of mental
health and prescription drugs. The commenter is concerned that if the
plan used as a benchmark does not cover mental health treatment or
prescription drugs, the new Medicaid benefit package does not have to
provide this coverage.
Other commenters are concerned about language indicating that a
benchmark-equivalent coverage package is not required to include
coverage for prescription drugs, mental health services, vision
services, or hearing services. The commenter believed all of these
services are necessary medical services.
Response: Section 1937 of the Act does not specifically require
that benchmark or benchmark-equivalent plans provide a full continuum
of care, nor does it guarantee all services that might be considered
medically necessary.
Furthermore, while all services described under section 1905(a) of
the Act are provided based on medical necessity, not all of those
services are considered mandatory Medicaid services that States must
include in the standard Medicaid plan. Prescription drugs, certain
mental health services, vision services, and hearing services are not
mandatory services under the State plan for adults. The DRA specifies
that if coverage for prescription drugs, mental health, vision and/or
hearing is provided in the benchmark plan, the benchmark-equivalent
plan must provide at least 75 percent of the actuarial value of the
coverage. If coverage is not provided under the benchmark plan, the
benchmark-equivalent plan is also not required to provide the coverage.
In calculating the actuarial value of the benchmark-equivalent, the
actuarial value would be calculated based only on the services included
in the specified benchmark plan and not calculated based on services
that are not included in that plan. This rule is consistent with the
statutory provision.
Comment: Some commenters questioned how the State will assure the
aggregate actuarial value is equivalent if there is lesser coverage in
prescription drugs, mental health, vision, and/or hearing services.
Response: Section 1937(b)(2)(C) of the Act specifies that, in
considering a benchmark-equivalent benefit, if prescription drugs,
mental health, vision, and/or hearing are provided in the benchmark
plan, the benchmark-equivalent must provide at least 75 percent of the
actuarial value of that coverage. This section specifies the minimum
coverage levels but does not specify the maximum level. Thus, States
have the option to cover these services at higher than 75 percent of
the actuarial value. To assure that the aggregate actuarial value is
equivalent, we required in Sec. 440.340 that, as a condition of
approval of benchmark-equivalent coverage, States must provide an
actuarial report that provides, among other things, sufficient detail
as to the basis of the methodologies used to estimate the actuarial
value of the benchmark-equivalent coverage.
Comment: Another commenter suggested that rehabilitation services
should be added to the list of services included at Sec. 440.335.
Response: The DRA specifies that benchmark-equivalent coverage must
include certain basic services; that is, inpatient and outpatient
hospital services; physicians' surgical and medical services;
laboratory and x-ray services; well-baby and well-child care including
age-appropriate immunizations; and other appropriate preventive
services. We have also specified the inclusion of emergency services,
and within the context of preventive services, family planning services
and supplies, but have left States with the flexibility to define other
appropriate preventive services.
It is important to note, however, that States, at their option, can
provide additional services to benchmark or benchmark-equivalent plans.
The inclusion of rehabilitation services may be appropriate for some
populations as determined by the State based on the requirements of the
population utilizing the benchmark plan. Additional services are
discussed in Sec. 440.360 of this rule.
We did not receive any additional comments to Sec. 440.340,
Actuarial report. Therefore, in this final rule, Sec. 440.340 will be
adopted as written in the proposed rule of February 22, 2008.
I. Section 440.345 EPSDT Services Requirement
Comment: Some commenters supported the proposed regulation that
would require individuals to first seek coverage of EPSDT services
through the benchmark or benchmark-equivalent plan before seeking
coverage of services through wrap-around benefits. Some commenters
believed that when individuals need to access additional services as a
wrap-around either for children or adults, States should be required to
ensure they continue to be able to receive services from the same
provider.
Response: It is important for individuals to receive services from
the same provider whenever possible and we believe that an individual's
physician is in the best position to ``manage'' an individual's care.
If an individual is entitled to additional services, the treating
physician should be responsible for providing and/or coordinating the
individual's care and should be aware of any additional services the
individual needs. To ensure that individuals under the age of 21
receive full EPSDT services we revised Sec. 440.345 to require States
to not only include a description of how additional benefits will be
provided, but also how access to additional benefits will be
coordinated and how beneficiaries and providers will be informed of
these processes.
Comment: Some commenters objected to the provision in the proposed
rule that stipulates that individuals must first seek coverage of EPSDT
services
[[Page 23088]]
through the benchmark plan before seeking coverage of these services
through wrap-around benefits. These commenters asserted that Congress
intended to allow States the option of providing these benefits
directly to Medicaid beneficiaries or to provide benefits in whole or
in part by the benchmark provider. They indicated that CMS provides no
justification as to why children must first wrestle with the
administrators of the benchmark benefit package before accessing EPSDT
services. One commenter asked that the rule be amended to eliminate the
requirement that a family first seek coverage of EPSDT services through
the benchmark plans.
Response: We believe that children enrolled in a benchmark benefit
plan should have a medical provider that serves as the ``medical home''
for the child and that this medical provider will coordinate the
child's care and facilitate access to specialists and necessary support
services.
It is the responsibility of the State Medicaid program to assure
that individuals enrolled in benchmark and benchmark-equivalent benefit
plans receive EPSDT services that can be accessed in the most
beneficial and seamless manner possible, and that individuals under 21
and their parent, guardian or care giver are informed and understand
how and where to gain access to these services. We therefore revised
Sec. 440.345 by removing the requirement that individuals must first
seek coverage of EPSDT services through the benchmark plan before
seeking coverage of these services through additional benefits.
Additionally, to further ensure that these individuals have access to
the full EPSDT benefit, we revised the requirement to include a
description of how the additional benefits will be provided, how access
to additional benefits will be coordinated and how beneficiaries and
providers will be informed of these processes. States must ensure that
information is given to the providers either through the State or
through the managed care entity in order to ensure that providers are
aware of the child's right to additional services, as necessary,
through the EPSDT benefit so that they can assist individuals with
accessing necessary care.
Comment: One commenter believed that families are unlikely to
realize that their children have access to more coverage than that
provided through the benchmark. Even if they understood, they may not
know how to request such a service. The commenter suggested that this
section be strengthened by requiring States to explain, in detail, how
a family will be informed of their rights under EPSDT once they are
enrolled in a benchmark plan and to explain the specific process the
State will then go through to approve or disapprove these services.
States should also explain timelines for consideration of EPSDT
requests in emergency, urgent and routine cases.
The commenter goes on further to say the preamble to the proposed
rule stated, ``the State may provide wrap-around * * * under such
plan.'' The commenter urged that CMS clarify that the word ``may''
should be replaced with ``must'' because the word ``may'' inaccurately
suggested that States are not required to provide these services. The
commenter noted that, in other areas of the proposed rule, CMS
correctly stated that EPSDT services must wrap-around benchmark plans.
Response: We agree that States should be required to inform
families of their rights under EPSDT. The commenter is correct that
children enrolled in benchmark or benchmark-equivalent plans may be
entitled to additional services. It should be noted that CHIPRA
underscored that full EPSDT services must be provided. Therefore, we
are clarifying that States must ensure that information is provided to
all EPSDT eligibles and/or their families about the benefits of
preventive health care, what services are available under the EPSDT
benefit, where and how to access those services, that transportation
and scheduling assistance are available, and that services are
available at no cost. This is consistent with the requirements of
section 1902(a)(43)(A) of the Act and current policy outlined in
Section 5121 of the State Medicaid Manual. Information must be given to
individuals no later than within 60 days of the individual's initial
Medicaid eligibility determination, and annually thereafter if they
have not utilized EPSDT services. We believe most States have booklets
to inform individuals of their benefits, rights, responsibilities, etc.
This information is typically presented to families by the eligibility
worker at the time of application and/or sent to individuals as part of
an enrollment packet from the managed care plan. These types of
documents must clearly explain the benchmark and additional benefits
available to EPSDT eligibles under the age of 21.
Additionally, we agree with the commenter that the word ``may'' was
inaccurate in the preamble to the proposed rule. The law specifically
requires States to provide additional services (if the full range of
EPSDT services is not provided as part of the benchmark or benchmark-
equivalent plan) to assure that all EPSDT services are available to
eligible individuals. We are providing clarification here in response
to the comment; however, we are not revising the regulation text, since
the language in Sec. 440.345 clearly indicates that this is a
requirement rather than a choice.
Comment: One commenter stated that the rule was silent on the
requirement that the state provide information in plain language that
is understood by the individual, parent or guardian including clear
instructions on how to access EPSDT services not provided by the
benchmark plan and how to disenroll.
Response: We agree that it is important that individuals be
provided with clear instructions in plain language on how to access
EPSDT services not provided by the benchmark plan and how to disenroll.
This is already required by the EPSDT outreach provisions of section
1902(a)(43) of the Act, which are applicable to alternative benefit
packages. To the extent that alternative benefit packages are delivered
through managed care plans, States must also comply with managed care
rules at 42 CFR part 438. According to Sec. 438.10, information
provided must be in an easily understood language and format.
Comment: One commenter noted that proposed Sec. 440.350 failed to
specify that under the employer-sponsored insurance plan option States
must still ensure that children have access to the wrap-around EPSDT
benefit. This section should be amended to note this requirement.
Response: The requirement to provide EPSDT benefits to children
under the age of 21 applies to benchmark and benchmark-equivalent
coverage. We have provided that States can offer premium assistance for
employer sponsored insurance if the insurance is considered a benchmark
or benchmark-equivalent plan. Additionally, we have indicated in Sec.
440.350(b) that the State must assure that employer sponsored plans
meet the requirements of benchmark or benchmark-equivalent coverage,
including the economy and efficiency requirements at Sec. 440.370. By
requiring that employer sponsored plans meet the requirements of
benchmark or benchmark-equivalent coverage, and given that benchmark or
benchmark-equivalent coverage must provide EPSDT to children under the
age of 21 either as part of or in addition to the benchmark or
benchmark-equivalent plan, we are requiring that any employer sponsored
insurance coverage provide EPSDT services to children under the age of
21. We believe this is
[[Page 23089]]
clear in the regulation, so we have not revised the regulation text in
this regard.
Comment: Another commenter believed that limiting the mandatory
EPSDT benefit to children under age 19 rather than under age 21 denies
19 and 20 years olds access to critical health care services. The
commenter stated that this provision is inconsistent with the title XIX
definition of EPSDT. Removing EPSDT for 19 and 20 years olds may
exacerbate existing health disparities for minority adolescents,
compromise 19 and 20 years olds' ability to transition successfully
into adulthood, and impede identification of physical and mental
conditions.
Response: Section 611 of CHIPRA raised the age for mandatory EPSDT
coverage from 19 to 21 years of age. We have changed the regulation
text accordingly.
Comment: One State Medicaid official suggested, instead of the
current language in the published proposed rule on (73 FR 9727) of the
Federal Register regarding EPSDT, the following amendment be made to be
consistent with Federal laws: ``(a) The State must ensure access to
EPSDT services, through benchmark * * * for any child under 19 years of
age eligible under the State plan in a category under section
1902(a)(10)(A) of the Act.''
Response: We have revised the rule to effectuate the clarification
provided by section 611(a)(1)(C) and 611(a)(3) of CHIPRA which requires
States to assure that children under the age of 21, rather than those
under 19 as originally specified in the DRA, have access to the full
range of EPSDT services.
I. Section 440.350 Employer-Sponsored Insurance Health Plans
Comment: One commenter requested information about enrollment in
commercial plans and suggested a discussion of how such arrangements
might actually be operationalized; that is, how premiums would be paid
and tracked, and the level of Medicaid contribution to such plans.
Response: Benchmark or benchmark-equivalent benefit coverage may be
offered through employer sponsored insurance health plans for
individuals with access to private health insurance. If an individual
has access to employer sponsored coverage and that coverage is
determined by the State to offer a benchmark or benchmark-equivalent
benefit package (either alone or in addition to services covered
separately under Medicaid), a State may elect to provide premium
payments on behalf of the individual to purchase the employer coverage.
Non-exempt individuals can be required to enroll in employer sponsored
insurance, and the premium payments would be considered medical
assistance. The requirement for children under the age of 21 to receive
EPSDT either as an additional service or as part of the benchmark
coverage would still be applicable. The premium payments and any other
cost-sharing obligations by beneficiaries would be subject to the
premium and cost-sharing requirements outlined in sections 1916 and
1916A of the Act, including the requirement that cost sharing not
exceed the aggregate limit of 5 percent of the family's income, as
applied on a monthly or quarterly basis specified by the state.
If the employer plan is economical and efficient, States have the
flexibility to take advantage of the coverage, without requiring a
uniform employer contribution. It is likely that a substantial employer
contribution would be necessary in order to meet the economy and
efficiency requirement. States must identify the specific minimum
contribution level that they are requiring of participating employers.
We have not approved any Medicaid benchmark programs at this time
that provide for employer sponsored coverage; however, we have approved
section 1115 demonstrations in which States have provided premium
assistance payments and employer sponsored insurance coverage to
Medicaid beneficiaries. For these section 1115 demonstration programs,
some States have required beneficiaries to provide proof of premium
assistance payments. Then, after such proof is received, the state
reimburses the beneficiary directly. Some States use a voucher system
in which they provide a monthly voucher directly to the beneficiary for
the premium payment in purchasing the employer sponsored insurance. We
are not specifying the way in which States operationalize employer
sponsored insurance benchmark plans; however, we provide this
information for consideration.
Comment: One commenter supported the inclusion of wrap-around
services in general and wrap-around services for employer sponsored
insurance plans as an option available to States, but did not support a
requirement for additional wrap-around services. The commenter
requested that language be added to describe the permissibility of
various types of market innovations in coverage such as high deductible
plans, health savings accounts, consumer-directed plans and wellness
plans or that there be language added indicating such market
innovations are acceptable as ``Secretary-approved coverage'' through a
State plan amendment.
Response: Section 1937(a)(1)(C) of the Act provides that additional
benefits are options that can be added by the State to benchmark or
benchmark-equivalent coverage. Any services that are added do not need
to include all State plan services; however, these additional services
must be coverable under the benefit categories under the benchmark plan
or under section 1905(a) of the Act.
The only requirement for additional services is at section
1937(a)(1)(A)(ii) of the Act, which provides that if children under the
age of 21 are receiving services in a benchmark or benchmark-equivalent
benefit plan, they are entitled to EPSDT services as defined in section
1905(r) of the Act and so must receive medically necessary services
consistent with EPSDT either as services provided in the benchmark or
as additional services to the benchmark plan.
We have further provided in Sec. 440.330 that Secretary-approved
coverage can be offered as benchmark coverage, consistent with the DRA.
This coverage must be appropriate to meet the needs of the targeted
population. We have required that States wishing to opt for Secretary-
approved coverage should submit a full description of the proposed
coverage and include a benefit-by-benefit comparison of the proposed
plan to one or more of the other benchmark options listed in this
section or to the State's standard full Medicaid coverage package under
section 1905(a) of the Act, as well as a full description of the
population that would be receiving the coverage. In addition, the State
should submit any other information that would be relevant to a
determination that the proposed health benefits coverage would be
appropriate for the proposed population. The scope of the Secretary-
approved health benefits package will be limited to benefits within the
benefit categories available under a benchmark coverage package or
under the standard full Medicaid coverage package under section 1905(a)
of the Act.
To the extent that a benchmark coverage plan that is used as the
comparison for the Secretary-approved benchmark plan provides for
market innovations such as high deductible health plans, health savings
accounts, consumer-directed plans, and/or wellness plans, we would
consider these on a case by case basis as components included in a
Secretary-approved benchmark option. It should be noted that CMS has
approved ten State benchmark programs. Of these ten, eight have been
approved as Secretary-approved programs. We did not receive any
additional comments related to Sec. 440.355 ``Payment of premiums.''
[[Page 23090]]
Therefore, in this final rule, Sec. 440.355 will be adopted as written
in the proposed rule of February 22, 2008.
J. Section 440.360 State Plan Requirement for Providing Additional
Services
Comment: A dental provider indicated that the proposed rules give
States the ability to create new benefit packages tailored to different
populations and that States have the flexibility to provide ``wrap-
around'' and ``additional benefits.'' The commenter noted that CMS
cited in a press release ``dental coverage'' as an example of
``additional benefits'' but, in the actual language of the proposed
rule there are no examples or reference to ``dental coverage.''
Further, the commenter noted that the conference report to the DRA
includes guidance to States by explaining that both benchmark and
benchmark-equivalent coverage would include ``qualifying child
benchmark dental coverage.'' The commenter also noted that in the
context of employer group health plans, stand-alone dental arrangements
are very often offered as a supplemental coverage that is separate from
medical care coverage. The commenter indicated that this option would
align Medicaid more closely with private market insurance options and
give States more control over their Medicaid benefit packages.
The commenter requested that CMS provide guidance to the States
with respect to ``additional benefits'' such as ``dental coverage.''
The commenter recommended the rule be amended to include an additional
paragraph that would provide that States have the option to provide
additional benefits that specifically include dental benefits that may
be offered as a supplement to medical care coverage.
Response: The DRA House Conference Report 109-362 provided for the
language that benchmark or benchmark-equivalent coverage would include
``qualifying child benchmark dental coverage.'' The conference
agreement removed this reference. Thus, the final provisions of section
1937 of the Act include no such requirement for the inclusion of dental
coverage as additional services nor does section 1937 of the Act
provide examples of additional coverage. The rule provides that
additional services do not need to include all State plan services but
would be health benefits that are of the same type as those covered
under the benchmark plan or considered to be health benefits under
section 1905(a) of the Medicaid statute.
We do agree that dental coverage could be added to benchmark or
benchmark-equivalent benefit plans. Further, it is possible that,
because of the plan options that have been identified by Congress as
benchmark coverage, dental services may already be covered services in
these plans.
If the commenter is concerned that children will not receive dental
coverage, we wish to point out that children under the age of 21 must
receive EPSDT services, including all medically necessary dental
services, consistent with section 1905(r) of the Act either as part of,
or as additional services to, the benchmark or benchmark-equivalent
plan. Therefore, medically necessary dental coverage must be provided
to children under the age of 21 enrolled in benchmark plans regardless
of whether or not the actual benchmark plan includes such coverage.
K. Section 440.365 Coverage of Rural Health Clinic and Federally
Qualified Health Center (FQHC) Services
Comment: One commenter was concerned that the proposed rule
stipulated that States with benchmark plans need only assure that these
individuals have access through such coverage and that FQHCs are to be
reimbursed for such services as provided under the FQHC reimbursement
requirements found in section 1902(bb) of the Act. The commenter
indicated further concern that CMS did not elaborate further on these
requirements, and particularly, that it did not lay out minimum steps a
State must take to assure that these patient and health center
protections are effectively implemented. The commenter believed it is
important that the final rule and preamble make clear that there are
minimum steps a State must take to be in compliance with these FQHC
statutory requirements.
Specifically, the commenter asked that it should be clear that
individuals who are mandatorily or voluntarily enrolled in a benchmark
plan: (1) Remain eligible to receive from an FQHC all of the services
included in the definition of the services of an FQHC, as provided in
section 1902(a)(2)(C); and (2) must be informed that one or several of
the providers by whom they may choose to be treated under this coverage
is (or are) an FQHC. The commenter asserted that, to the extent these
same individuals receive benchmark coverage, both the State and the
benchmark plans must be encouraged to contract with FQHCs as providers
of services to these enrolled Medicaid populations. These FQHC(s) must
be identified by name. The commenter further stated that, in the event
the benchmark plans identified do not contract with an FQHC, enrollees
must be informed that they still may receive Medicaid covered services
from FQHCs. In the preamble and final rule, the commenter provided that
CMS should underline to the States the importance of full compliance
with the FQHC reimbursement requirements of section 1937(b)(4) of the
Act and Sec. 440.365. The commenter added that adoption of these
recommendations is important to assure that the requirements of section
1937(b)(4) of the Act are met.
Response: We agree with the commenters and we have required in
Sec. 447.365 that if a State provides benchmark or benchmark-
equivalent coverage to individuals, it must assure that the individual
has access, through that coverage or otherwise, to rural health clinic
services and FQHC services and that payment for these services must be
made in accordance with the payment provisions of section 1902(bb) of
the Act. We also agree that individuals always have access to FQHC
services, even if the State does not contract with an FQHC to provide
such services, and we encourage States to contract with FQHCs as
providers.
We did not receive any comments to Sec. 440.370. Therefore, we
will adopt Sec. 440.370 as written in the proposed rule of February
22, 2008 with the change of the title to ``Economy and Efficiency''
which more appropriately reflects Medicaid payment principles.
L. Section 440.375 Comparability
Comment: One commenter encouraged CMS to require comparability
across traditional Medicaid and Medicaid benchmark alternatives.
Response: The language included in the rule allowing States to
offer benchmark or benchmark-equivalent health care coverage without
regard to comparability is based on the DRA language providing that
``notwithstanding any other provision of Title XIX'' States can offer
medical assistance to certain Medicaid beneficiaries through benchmark
or benchmark-equivalent benefit packages. Section 611 of CHIPRA
clarified and narrowed the ``notwithstanding'' provision but did
specifically mention comparability.'' Therefore, it is clear that
States may offer benchmark or benchmark-equivalent coverage to certain
specified Medicaid populations. This regulation provision gives meaning
to the statutory language permitting States to offer benchmark or
benchmark-equivalent coverage to certain, but not all, Medicaid
populations.
We would note that States can design disease management services
without
[[Page 23091]]
relying on DRA benchmark or benchmark-equivalent plans, as outlined in
the March 31, 2006 State Medicaid Director letter, which provided
guidance on the implementation of section 6044 of the DRA but this
benchmark option offers another way for States to meet the needs of
their Medicaid populations.
M. Section 440.380 Statewideness
Comment: One commenter is concerned that States are given the
option to amend their State plan to provide benchmark plan coverage to
Medicaid individuals without regard to statewideness. This proposed
regulation would likely result in health care disparities among
individuals living in different parts of the State, has no basis in the
statute, and should therefore be excluded from the final regulations.
The commenter stated that the proposed Sec. 440.380 should be revised
to ensure that beneficiaries across the State are not subject to
disparities in health care services.
Response: The language included in the rule allowing for States to
offer benchmark or benchmark-equivalent health care coverage without
regard to statewideness is based on the DRA language providing that
``notwithstanding any other provision of title XIX'' and the more
narrow and explicit language in CHIPRA which specifically states
``Notwithstanding statewideness * * *''. It is therefore clear that
States could offer different benchmark or benchmark-equivalent coverage
to Medicaid individuals in different regions within the State. This
provision also gives meaning to the language permitting States to offer
benchmark or benchmark-equivalent coverage to certain, but not all,
Medicaid populations.
For example, States can test new benefit concepts in pilot areas
before expanding the benchmark program to the entire State. We believe
that this is consistent with Congressional intent in allowing
flexibility regarding statewideness for benchmark benefit options.
N. Section 440.385 Freedom of Choice
Comment: One commenter noted that CMS protects the free choice of
emergency services providers but failed to do so for family planning
services providers. The commenter urged CMS to preserve the free choice
of family planning services providers by amending the rule to include a
provision preserving the free choice of family planning providers. The
commenter believes that this has been a long-standing policy of the
Congress and the Medicaid program.
The commenter added that the proposed rules would permit States to
deny freedom of choice of a provider for managed care enrollees seeking
family planning services and supplies. The commenter argued that this
provision lacks any basis in the statute and is contrary to the clear,
repeated articulated intent of Congress.
The commenter asserted that provider freedom of choice is critical
because of the potentially sensitive nature of the service. The
commenter argued that, if unable to obtain confidential services from
the provider of their choice, some managed care enrollees may forgo
obtaining family planning services entirely. This would threaten
beneficiaries' access to high quality, confidential reproductive health
care and set a precedent of inequity between beneficiaries in fee-for-
service programs and beneficiaries in managed care plans.
The commenter noted that Congress has clearly indicated that while
States may require Medicaid beneficiaries to enroll in managed care
plans and obtain care from providers affiliated with those plans, an
exception should be made for individuals seeking family planning. The
commenter also noted that Federal regulations at Sec. 431.51 state,
``A recipient enrolled in a primary care case management system, a
Medicaid MCO, or other similar entity will not be restricted in freedom
of choice of providers of family planning services.'' The commenters
urged the Department to revise Sec. 440.385 to reflect that provider
freedom of choice for family planning should be retained.
Response: Section 1937(a)(1) of the Act, as amended by section 611
of CHIPRA, narrowed the flexibility States have and we amended Sec.
440.385 by removing the option to provide benchmark benefit plans
without regard to the requirements for free choice of providers at
Sec. 431.51 of this chapter.
CHIPRA also made it clear that benchmark benefit programs may vary
only from the requirements for statewideness, comparability, and ``any
other provision of this title which would be directly contrary to the
authority under this section and subject to subsection (E).'' Title XIX
permits States the option to offer Medicaid through managed care
entities. Thus, requiring States to comply with Medicaid managed care
statutes and regulations would not be directly contrary to the
authority of section 1937 of the Act. We have therefore revised the
regulation at Sec. 440.385 to clarify that States wishing to deliver
benchmark and benchmark-equivalent packages through a managed care
entity may do so but must comply with the requirements of section 1932
of the Act, 42 CFR part 438, and any other provisions of title XIX or
the regulations pertaining to managed care.
Comment: One commenter requested that CMS explain the concept of
``selective contracting'' and provide more detail as to how this would
be operationalized under benchmark plans.
Response: Selective contracting is a term usually referred to in
the context of section 1915(b)(4) waiver programs or 1932(a) under the
State plan. Selective contracting provides States with the opportunity
to contract with certain providers, practitioners or managed care
entities so long as certain other criteria are maintained.
Specifically, the State must ensure that in order to selectively
contract with providers, practitioners or managed care entities the
selective process does not restrict providers in emergency situations
or providers of family planning services and supplies; is based on
reimbursement, quality and utilization standards under the State plan;
and does not discriminate among classes of providers on grounds
unrelated to their demonstrated effectiveness and efficiency in
providing benchmark benefit packages.
Section 1937(a)(1) of the Act as amended by section 611 of CHIPRA
allows selective contracting through benchmark or benchmark-equivalent
plans when provision of free choice of providers would be directly
contrary to efficient and effective operation of the proposed benchmark
benefit program.
Comment: One commenter noted that CMS should include an ``any
willing provider'' provision in Medicaid contracts for alternate plans
that allow Medicaid participating providers the opportunity to continue
serving those who are required by the State to enroll in a benchmark
plan.
Response: Based on changes made by CHIPRA to section 1937 of the
Act States must comply with all freedom of choice requirements under
title XIX except to the extent the State can demonstrate that freedom
of choice would be contrary to the effective and efficient
implementation of a benchmark or benchmark-equivalent plan. We
therefore revised Sec. 440.385 by striking the option for States to
provide benchmark benefit plans without regard to the requirements for
freedom of choice. This revision eliminates the need to include an
``any willing provider'' provision.
[[Page 23092]]
O. Section 440.390 Assurance of Transportation
In responding in this final rule to all of the comments received we
took into consideration the numerous remarks on the subject of
transportation which generally disagreed with the provision in the
proposed rule and the rule published December 3, 2008 that would allow
States the option to exclude non-emergency medical transportation
(NEMT) as a benefit under benchmark and benchmark-equivalent plans. In
addition to considering these comments we now must also consider the
new CHIPRA legislation which clarifies that the authority under section
1937 to deviate from otherwise applicable Medicaid requirements is
limited.
It is true that benchmark benefit packages such as Federal
Employees Health Benefit Plan coverage, State Employees Health Benefit
coverage, and coverage offered by an HMO in the State with the largest
insured commercial non-Medicaid population, generally do not cover non-
emergency medical transportation (NEMT) to and from medical providers.
However, pursuant to section 1902(a)(4) of the Act and 42 CFR 431.53
there is a general requirement that the State plan assure necessary
transportation to and from providers for beneficiaries when needed to
access Medicaid covered services. The CHIPRA amendment to the DRA made
it clear that Medicaid provisions that are not directly contrary to the
provision of services under benchmark or benchmark-equivalent plans
continue to apply under the DRA benchmark provisions. Therefore, in
accordance with the changes made to the DRA by CHIPRA, and since this
assurance of NEMT would not directly conflict with the offering of
benchmark or benchmark-equivalent benefit packages as authorized by
section 1937 of the Act, the assurance of necessary transportation to
and from providers remains applicable when a State elects the 1937
option, and regardless of whether it is or is not a covered benefit
under a benchmark or benchmark-equivalent benefit plan.
Thus, we have revised the regulation at Sec. 440.390 to require
States to assure necessary transportation to and from providers for
beneficiaries enrolled in benchmark and benchmark-equivalent plans,
even if the plans themselves do not include transportation.
States have several options when assuring necessary transportation
for beneficiaries enrolled in a benchmark or benchmark-equivalent plan.
States may provide transportation and transportation-related services
under a benchmark plan as provided at Sec. 440.330 (FEHB plan, State
Employees plan, Commercial HMO plan or Secretary-approved plan); under
a benchmark-equivalent plan as an additional service as provided at
Sec. 440.335; or as an additional service as provided at Sec.
440.360, and receive Federal financial participation (FFP) at the
Federal matching rate designated for that State for covered Medicaid
services (FMAP rate).
If transportation and transportation-related services or some
portion of the transportation provided for beneficiaries enrolled in a
benchmark or benchmark-equivalent plan is not covered under section
1937 of the Act, then such transportation and transportation-related
services must be claimed as an administrative expense at the 50 percent
Federal matching rate. If transportation and transportation-related
services are claimed as a medical service under section 1937 of the
Act, the State must adhere to the general Medicaid requirements which
pertain to claiming transportation as a medical service, such as only
claiming direct vendor payments.
Our responses to the following comments received on transportation
reflect the changes made by section 611 of CHIPRA, which clarifies that
the authority under section 1937 to deviate from otherwise applicable
Medicaid requirements is limited and therefore the assurance of
transportation remains applicable even when the State has elected the
section 1937 option.
Comment: One commenter agreed with the interpretation of the
``notwithstanding'' language to ``bypass'' the assurance of
transportation, including the elimination of non-emergency medical
transportation (NEMT). The commenter noted that the ability of States
to exclude NEMT services in their benchmark benefits is evident not
only from the broad language of the statute but also from Congressional
intent. The commenter noted that one of the stated purposes of section
6044 of the DRA is to allow States to offer benefit packages that
mirror commercial packages.
Response: The benchmark options that Congress specified, Federal
Employees Health Benefit Plan equivalent coverage, State employees
coverage, and coverage offered by an HMO in the State with the largest
insured commercial non-Medicaid population, generally do not pay for
NEMT to and from medical providers in all instances. However, section
611(a)(1)(A)(i) of CHIPRA changed the ``notwithstanding any other
provision of this title'' language and this change in the law clarifies
that the authority under section 1937 to deviate from otherwise
applicable Medicaid requirements such as those specified in section
1902(a)(4) of the Act and 42 CFR 431.53, which require States to assure
that beneficiaries have access to covered medical services, is limited.
Accordingly, we have revised the regulation at Sec. 440.390 to require
States to assure necessary transportation to and from providers.
Comment: A preponderance of commenters disagreed with the provision
in the rule that would allow States the option to exclude NEMT as a
benefit under a benchmark and benchmark-equivalent plan. Generally,
these comments were submitted by transportation providers, medical
providers, and Medicaid beneficiaries, particularly Medicaid
beneficiaries who rely on dialysis treatments.
Most of the commenters believed that the goals of the Medicaid
program would be undermined if needy individuals were unable to get to
and from healthcare services and such an option would create a barrier
to care. They asserted that assurance of transportation is a vital
component of the Medicaid program and is of particular importance to
mentally and physically disabled and elderly patients. They expressed
concern that vulnerable populations might not receive medically
necessary and often life sustaining services because of the difficulty
in accessing needed care and provided examples of the negative impact
on the Medicaid program that would be created by not assuring
transportation. For example, patients with End-Stage Renal Disease
(ESRD), would be unable to access dialysis services.
Many of the commenters focused on the impact that the proposed
regulation would have on dialysis patients who require 3 weekly trips
to and from dialysis facilities in order to survive. They noted that
effective care of ESRD patients requires meticulous coordination of
dialysis treatment and drug therapy with frequent and specialized care.
Dialysis patients often have multiple co-morbidities and, therefore,
require frequent transportation to multiple services. The severity of
the complications that develop due to missed treatments is often life
threatening. Elimination of transportation services would make it very
difficult and often impossible for beneficiaries with ESRD to
consistently access the frequent dialysis services that sustain their
lives.
Many commenters stated that individuals with physical or mental
disabilities have difficulty using public
[[Page 23093]]
transportation and require specialized transportation that would
otherwise not be available should State Medicaid programs be allowed to
stop providing transportation. For many beneficiaries, the cost of
frequent trips in specialized vehicles would be unaffordable. Often
beneficiaries live in rural areas where the only available
transportation to and from medical appointments is provided through the
Medicaid program. Without Medicaid transportation services, many
beneficiaries would be unable to access needed care and ultimately
would require more costly services, costly emergency care, and
expensive emergency ambulance services and/or expensive non-medical
wheelchair van care.
Other commenters indicated that co-occurring physical health
conditions such as diabetes or heart disease, as well as mental health
conditions such as depression and anxiety affect an individual's
ability to drive.
Several commenters indicated that people suffering with HIV/AIDS,
some in wheelchairs, others who are extremely fragile or elderly, have
monthly office visits where they are assessed and treated. To remove
their only means of free transportation will take away their compliance
with medical office treatment.
Response: In light of these comments and because CHIPRA amended
section 1937 of the Act by clarifying that the authority to deviate
from otherwise applicable Medicaid requirements is limited, we have
revised the regulation at Sec. 440.390 to require States to assure
necessary transportation to and from providers. Thus, the frail,
elderly, disabled and those with ESRD will be entitled to receive
transportation to and from medical providers.
Comment: Several commenters noted that elimination of the
requirement to provide transportation would actually drive up Medicaid
costs because medical visits would become less frequent, resulting in a
higher incidence of more serious and costly medical problems, an
increase in the use of emergency medical services, and an increase in
long term nursing home admissions. A number of these commenters cited a
2006 Cost Benefit Analysis conducted by the Marketing Institute of
Florida State University College of Business as proof of the cost
effectiveness of providing NEMT to Medicaid beneficiaries. Another
commenter cited several studies that compared Medicaid individuals
residing in States that do provide access to NEMT. The commenter stated
that these studies found that access to non-emergency transportation
produces cost savings and increased health care results. For many
beneficiaries, the cost of frequent trips in specialized vehicles would
be unaffordable. Often beneficiaries live in rural areas where the only
available transportation to and from medical appointments is provided
through the Medicaid program. Without Medicaid transportation services,
many beneficiaries would be unable to access needed care and ultimately
would require more costly services, costly emergency care, and
expensive emergency ambulance services and/or expensive non-medical
wheelchair van care.
One commenter indicated that coordinating transportation would
reduce the cost of providing transportation. Another commenter
indicated that CMS requires States to comply with economy and
efficiency principles in offering benchmark or benchmark-equivalent
benefit packages to Medicaid beneficiaries, but does not require non-
emergency medical transportation in benchmark or benchmark-equivalent
plans, when according to several studies it has been proven that
providing this service is cheaper overall and leads to better health
outcomes for Medicaid beneficiaries.
Response: CHIPRA amended section 1937 of the Act by clarifying that
the authority to deviate from otherwise applicable Medicaid
requirements is limited and we have therefore revised the regulation at
Sec. 440.390 to require States to assure necessary transportation to
and from providers.
Comment: One commenter suggested that this rule sets up a system
that would limit mileage payments to drivers for non-emergency doctor
visits. The commenter indicated that medical mileage is funded in part
to drivers who transport people for medical care on a non-emergency
basis.
Response: We do not understand the relevance of this comment to the
provision of benchmark and benchmark-equivalent benefit plans and are
therefore unable to respond.
Comment: One commenter stated that the number one reason that
dentists and doctors do not wish to accept Medicaid patients is that
Medicaid beneficiaries do not show-up for appointments or are late for
appointments. If CMS does not require transportation benefits, no-shows
will increase and the result will be that fewer providers will
participate in Medicaid.
Response: As we previously stated, CHIPRA amended section 1937 of
the Act by clarifying that the authority to deviate from otherwise
applicable Medicaid requirements is limited and we have revised the
regulation at Sec. 440.390 to require States to assure necessary
transportation to and from providers. Therefore, the commenter's
concern about the lack of transportation contributing to missed
appointments and late appointments has been addressed.
Comment: Many commenters stated that the possible elimination of
transportation will not only decrease access to healthcare but would
imperil the financial stability of ambulance services across the
Emergency Medical Services (EMS) community. EMS providers depend on
reimbursement from non-emergency transports to sustain operational
costs and maintain optimal readiness standards for emergency
transports. Without adequate reimbursement from Medicaid for non-
emergency transports, many ambulance providers, especially those in
rural areas, would cease to stay in business, causing a serious
reduction in the overall availability of ambulance services. Many
commenters stated the provision would likely cause over-utilization of
emergency ambulance services, since beneficiaries would need to rely
more frequently on more expensive emergency ambulance transport.
One commenter suggested that CMS implement the same ``medically
necessary transportation'' guidelines for the Medicaid program that
already exist and govern non-emergency ambulance transportation for
Medicare patients, because commercial insurance almost universally uses
these guidelines as the benchmark for reimbursement for non-emergency
ambulance transportation.
One commenter noted that the GAO has found that the current
Medicare rates for ambulance transportation is on average 6 percent
below the cost of providing care. Medicaid rates are currently even
less. Ambulance transportation is a vital service for Medicaid
beneficiaries, and ambulance companies are currently operating under a
fee schedule that does not compensate them for the cost of providing
that care. To further reduce the overall reimbursement to the ambulance
providers while leaving benefits intact for hospitals, physicians, and
labs is unfair. Ambulance transport is a vital link between the patient
and these other services, and should not be relegated to non-payment.
Response: CHIPRA clarified that the requirement to assure necessary
transportation applies to benchmark and benchmark-equivalent benefit
plans.
With regard to the comment that CMS require for benchmark and
benchmark-equivalent benefit plans the same
[[Page 23094]]
ambulance transportation guidelines used by commercial insurance, we
disagree with this comment because there is no authority under section
1937 of the Act to do so.
Comment: Many commenters indicated that the proposed rule would
shift financial responsibility for Medicaid non-emergency
transportation to non-profit and municipal fire service-based emergency
medical systems (EMS), ADA paratransit programs, beneficiaries,
beneficiaries' families, and other segments of the population who often
do not have sufficient funds to pay for trips to and from providers.
The commenters believed that the proposed cuts in transportation
conflict with the protections afforded to the disabled under the
Americans with Disabilities Act. Some commenters stated the shifting of
the financial burden for Medicaid non-emergency transportation to ADA
paratransit services and local transit programs without any additional
funding constitutes an unfunded mandate.
Response: Because CHIPRA clarified that the assurance of necessary
transportation is applicable to benchmark and benchmark-equivalent
benefit plans, we revised the regulation in Sec. 440.390 to require
States to assure necessary transportation. Therefore, we do not believe
that the responsibility for Medicaid NEMT will be shifted to municipal
EMS systems, ADA paratransit programs, or beneficiaries. Consistent
with Federal regulations, States are required to assure non-emergency
transportation when the beneficiary has no other means of
transportation.
Comment: Several commenters stated that under section 1937 of the
Act, a benchmark-equivalent package must offer a specific range of
services set forth in Sec. 440.335(b)(1)-(5) of the proposed
regulation and that the majority of qualifying benchmark plans cover
emergency ambulance services. To ensure that enrollees in benchmark-
equivalent plans receive coverage that is qualitatively equivalent to
benchmark plans that provide emergency ambulance transportation, CMS
should require benchmark-equivalent plans to cover emergency ambulance
transportation.
Response: CHIPRA clarified that the assurance of necessary
transportation is applicable to benchmark and benchmark-equivalent
plans. We therefore revised the regulation at Sec. 440.390 to require
States to assure all necessary transportation.
Comment: One commenter noted that instead of saving money by
eliminating non-emergency transportation, CMS should do a better job of
policing the system to reduce fraud and abuse.
Response: The reduction of fraud and abuse should always be
considered by States when designing or implementing their State
Medicaid program and we expect States to implement policies that reduce
fraud and abuse. CMS will review the provision of these services
consistent with our responsibility to work with States to reduce fraud
and abuse in the program.
Comment: One commenter believed that during the DRA process CMS
attempted to end the Medicaid transportation service. This attempt was
turned back by Congress with the clear intention that transportation
was essential for adequate access to health services and it is clear
that the proposed rule is contrary to the intent of Congress.
Response: CMS did not attempt to end the requirement for States to
assure Medicaid non-emergency transportation. On August 23, 2007, CMS
published a rule on the ``State Option to Establish a Non-Emergency
Medical Transportation Program'' which intended to enhance the ability
of States to provide NEMT by offering an additional option for
providing more cost effective non-emergency transportation as a medical
service through a brokerage program. Furthermore, we have revised the
regulation at Sec. 440.390 to require States to assure necessary
transportation for beneficiaries enrolled in benchmark and benchmark-
equivalent plans.
Comment: One commenter noted the proposed rule on the ``State
Option to Establish a Non-Emergency Medical Transportation Program''
providing guidance on section 6083 of the DRA and wonders how CMS on
one hand is providing guidance regarding non-emergency medical
transportation and encouraging use of a brokerage program, while on the
other hand proposing elimination of non-emergency medical
transportation in benchmark or benchmark-equivalent plans.
Additionally, the commenter believed that the transportation
benefit currently operates in a fiscally sound manner. As currently
structured, the commenter asserted that the transportation benefit is
cost effective in most States. The commenter noted that States
generally limit reimbursement for transportation to the least costly
form of transport that is medically appropriate based on the
beneficiary's condition. Moreover, Medicaid beneficiaries are generally
required to use free transportation resources before the program will
provide reimbursement for transportation. The commenter stated that,
consequently, patients who receive transportation under state Medicaid
programs are required, as a condition of coverage, to have no other
means of getting to or from providers of medical care.
Response: Because CHIPRA clarified that the requirement for States
to assure necessary transportation is applicable to section 1937 of the
Act, we revised the regulation in Sec. 440.390 to require States to
assure necessary transportation for beneficiaries enrolled in
alternative benefit plans. Therefore, the brokerage program option for
delivering non-emergency medical transportation and the benchmark or
benchmark-equivalent benefits option do not contravene each other as
the commenter suggests.
Comment: A few commenters stated that in the proposed rule CMS
proposed to create more ``flexibility'' for States by allowing them to
craft more mainstream packages like those found in the private health
insurance market, and private health plans do not offer transportation
as a covered benefit for enrollees. These commenters disagreed with
this assumption because it presumes that Medicaid patients are of equal
financial standing with enrollees of private health care plans in their
ability to assume the cost of transportation to and from health care
services and that private health plans do not provide non-emergency
ambulance transportation, when in fact they do.
Response: The changes made to section 1937 of the Act by the CHIPRA
legislation make it clear that regardless of whether NEMT and emergency
ambulance services are included in the benchmark or benchmark-
equivalent plan the State has chosen to offer Medicaid beneficiaries,
the requirement to assure necessary transportation for eligible
Medicaid beneficiaries remains applicable.
Comment: One commenter stated that CMS did not conduct an analysis
of the impact that excluding the transportation benefit would have on
the populations affected or on the States. The commenter also noted
that in the ``Regulatory Impact Analysis,'' CMS states that they are
under no obligation to assess anticipated costs and benefits of this
rule, even if the rule may result in expenditures by the State, local,
or tribal governments of the private sector, because States are not
mandated to participate in the benchmark plans. This precludes any
discussion of the shift in costs to other agencies that may result from
the exclusion of transportation benefits. The commenter stated that in
the proposed rule CMS says that shifting the financial burden to the
vulnerable Medicaid populations is simply a matter
[[Page 23095]]
of personal responsibility. The commenter believed that the elimination
of transportation is a scenario for less effective, more expensive
health care because fewer people will seek preventive care since they
won't have transportation and will therefore end up needing more
expensive medical services.
Response: We revised the regulation in Sec. 440.390 to require
States to assure necessary transportation for beneficiaries enrolled in
benchmark and benchmark-equivalent benefit plans and have therefore
revised the ``Regulatory Impact Analysis,'' to account for the impact
of providing transportation.
Comment: Several commenters noted the lack of definition addressing
the difference between emergency and non-emergency transportation.
Several other commenters requested that CMS provide a universal
definition of non-emergency transportation, because without this
guidance there would be chaos and an inability to adjudicate issues and
disputes over what is and is not non-emergency transportation.
One commenter urged CMS to require that benchmark and benchmark-
equivalent plans cover emergency ambulance transportation and do so by
clarifying that the reference to ``emergency services'' in proposed
Sec. 440.335 include emergency ambulance services. Several commenters
stated the regulation fails to make a distinction between emergency and
non-emergency transport and CMS assumes that ``to and from providers''
means non-emergency medical transportation however this may not always
be the case. According to the commenter, transport is often required
for Medicaid patients who develop critical conditions that require
immediate care beyond the scope of the initial facility, resulting in
the patient being transported to another facility for care. If States
are no longer required to ensure necessary transportation for
individuals to and from providers, the State will likely not cover this
type of transport under a benchmark or benchmark-equivalent plan. This
type of transport fits the parameters of the regulation because it is
from one provider to another, but the regulation does not make the
distinction that it must be a non-emergency transport.
Other commenters believed ambulance service, whether considered
non-emergency or emergency transportation should be required in all
benchmark or benchmark-equivalent plans.
Response: Since CHIPRA clarified that the assurance of necessary
transportation is a mandatory State plan requirement that applies to
section 1937 of the Act, we have revised the regulation at Sec.
440.390 to require States to assure necessary transportation.
Therefore, the commenter's concerns regarding the provision of
emergency transportation services and the need for States to properly
distinguish between emergency and non-emergency transportation services
have been addressed.
Comment: A number of commenters disagreed with the assumption that
non-emergency transportation is not covered by private health
insurance. They stated that many private health insurance plans do
provide coverage for non-emergency ambulance transportation when
medically necessary. One commenter stated that CMS is ignoring the fact
that many commercial plans have provided services to Medicaid
beneficiaries and are thus equipped to provide the transportation
benefit. The same commenter requested that if the provision on non-
emergency transportation remains in the final regulation, CMS should
require that no benchmark or benchmark-equivalent plan be allowed to
require emergency ambulance services to join a network as a condition
of obtaining necessary information for billing or as a condition of
prompt payment, and that benchmark and benchmark-equivalent plans be
required to pay for emergency ambulance transportation at a rate not
less than the State Medicaid approved rate. One commenter noted that if
CMS intends to make this a rationale for the elimination of Medicaid
benefits, it should first study this issue and release its findings.
Response: In accordance with changes made by CHIPRA to section 1937
of the Act and the clarification these changes provided we revised the
regulation at Sec. 440.390 to require States to assure necessary
transportation.
Comment: Many of the commenters voiced concerns that CMS has
overreached in its rationale for allowing States to opt-out of the
transportation requirements, and that CMS did not support its
rationale. Several commenters stated that CMS did not have the legal
authority to allow States to choose not to provide non-emergency
transportation. One commenter stated that Sec. 440.390 exceeds the
Department's administrative authority, results in an impermissible
legislative action by the agency, and violates the separation of powers
doctrine of the Constitution. Generally, an executive agency's
authority is limited to implementing laws and to clarifying ambiguities
in statutes passed by Congress. The commenter cites Chevron U.S.A. v.
Natural Resources Defense Council, 467 U.S. 837 (1984).
A number of commenters noted that CMS's interpretation of the
language in section 1937 of the Act is ``overbroad'' because it permits
CMS too much discretion. Several commenters also stated that in
believing that it could change a long standing Medicaid policy on the
assurance of transportation, CMS wrongly interpreted the statute and
had not supported its rationale for allowing States to waive the
provider-to-provider transportation requirement. A number of commenters
believed that allowing States to choose not to provide transportation
was inconsistent with Medicaid's mission of increasing access to
healthcare. Many commenters indicated that exempting States from the
transportation requirement set forth in Sec. 431.53 ``renders those
provisions to mere surplusage'' and that CMS's interpretation affords
CMS the unfettered ability to make ad hoc determinations about what
laws and regulations will apply to benchmark and benchmark-equivalent
plans. Many commenters stated that the requirements in Sec. 431.53
exist to protect beneficiaries and to ensure that they receive access
to healthcare. Also, CMS should not be permitted to allow States to
deprive Medicaid individuals of necessary transportation based upon an
illogical interpretation of a provision of the Act.
Several commenters stated that CMS is providing sufficient
flexibility to States through the option to provide benchmark or
benchmark-equivalent coverage without regard to comparability,
statewideness, and freedom of choice. The commenter did not see how
relieving the State of the requirement to assure transportation to and
from providers offers any additional flexibility.
Response: Section 611(a)(1)(C) of CHIPRA amended the
``notwithstanding any other provision of this title * * *'' language.
This change in the law clarifies that the authority under section 1937
to deviate from otherwise applicable Medicaid requirements is limited.
Therefore, we have revised the regulation at Sec. 440.390 to require
States to assure necessary transportation to and from providers.
Comment: Several commenters mentioned earlier that CMS offered a
definition of ``special medical needs'' but pointed out that CMS did
not offer a definition of ``medically frail.'' The commenters urged
CMS, in considering transportation, to include in any definition of
``medically frail'' an individual who might require medically necessary
ambulance transportation due
[[Page 23096]]
to their physical or mental condition, illness, injury, disability, in
a bed confined or wheelchair confined state, such that transportation
by any means other than ambulance would likely jeopardize the patient's
health or safety.
Response: As stated earlier, while CMS wishes to maintain some
State flexibility in defining the term medically frail we have provided
further guidance on the characteristics of medically frail and special
needs individuals. We expect States to take this guidance into
consideration when determining what type of transportation is needed by
these individuals.
Comment: Several commenters stated the proposed elimination of
transportation was discriminatory because individuals with special
needs are not able to access transportation services and will be de
facto denied the medical services that other Medicaid individuals
receive. Also, the commenters asserted that the statutory provision
authorizing use of benchmark and benchmark-equivalent plans,
``notwithstanding any other provision of this title'' will not pass a
challenge in the court system because it discriminates against disabled
individuals.
Response: Section 611(a)(1)(C) of CHIPRA amended the
``notwithstanding any other provision of this title'' language. This
change in the law clarifies that the authority under section 1937 to
deviate from otherwise applicable Medicaid requirements is limited.
Accordingly, we revised the regulation at Sec. 440.390 to require
States to assure necessary transportation to and from providers for
individuals, including those with special needs, who are enrolled in
benchmark and benchmark-equivalent benefit plans.
Comment: Several commenters noted that Executive Order 13330
requires coordination for elderly and handicapped transportation
programs among Federal agencies. Creating Federal DHHS standards for
appropriate service levels would promote this coordination effort and
in the interests of quality services, lower costs and enhanced
coordination, DHHS should develop parallel standards that would drive
cost savings derived by competitive procurement instead of denying
services to those who need it the most. Removing an essential element
such as transportation in order to save money will ultimately result in
greater reliance on institutional care at a much higher cost. One
commenter believed that CMS should withdraw the regulation and allow
the Coordinating Council on Access and Mobility, which was established
by Executive Order 13330, to develop the benchmark policy on non-
emergency transportation.
Response: Section 611(a)(1)(C) of CHIPRA amended the
``notwithstanding any other provision of this title'' language. This
change in the law clarifies that the authority under section 1937 to
deviate from otherwise applicable Medicaid requirements is limited.
Accordingly, we revised the regulation at Sec. 440.390 to require
States to assure necessary transportation to and from providers. We do
not believe that Executive Order 13330, which relates to the
coordination of transportation among Federal agencies, is relevant to
this rule as this rule pertains to the provision of transportation by
States under State Medicaid programs.
Comment: One commenter, submitting on behalf of the Alaska Natives
(ANs) Tribal Health Consortium, wrote that in Alaska nearly 40 percent
of the Medicaid eligible populations are ANs. The vast majority of AN
villages are accessible only by plane, boat, snow-machine, or dog-sled.
Due to the extreme poverty found in AN villages, Congress authorized
tribal health programs to bill the Medicare and Medicaid programs for
covered services. Tribal health services rely heavily on Medicaid and
Medicare payments. The commenter is profoundly concerned that the
proposed rule would allow States to curtail Medicaid coverage of
crucial health services currently provided to ANs and would eliminate
coverage of transportation needed by ANs to access medical services.
Response: We recognize the important value of Medicaid
transportation services to the AN population. As stated previously
CHIPRA amended the ``notwithstanding any other provision of this title
* * *'' language and this change in the law clarifies that the
authority under section 1937 to deviate from otherwise applicable
Medicaid requirements is limited. Therefore, we have revised the
regulation at Sec. 440.390 to require States to assure necessary
transportation to and from providers for those enrolled in benchmark
and benchmark-equivalent benefit plans.
IV. Provisions of the Final Regulations
In general, this final rule incorporates the provisions of the
February 2008 proposed rule and the changes made by CHIPRA. The
provisions of this final rule that differ from the February 2008
proposed rule are as follows:
Scope (Sec. 440.305)
We added a new paragraph (d) at Sec. 440.305 to require public
input before States submit a State plan amendment under this section of
the law. We removed the exception at Sec. 440.305(e) to the managed
care rules that existed in the February 22, 2008 proposed rule because
section 611(a) of CHIPRA required adherence to all rules except those
directly contrary to the authority under this section. By removing this
exception to the managed care rules all benchmark and benchmark-
equivalent benefit plans that are delivered through a managed care
entity must comply with managed care rules.
Exempt Individuals (Sec. 440.315)
We revised paragraph (f) at Sec. 440.315 to indicate that States
will have flexibility in adopting definitions of individuals who are
``medically frail'' and/or individuals with special medical needs, but
that these definitions must at least include those individuals
described in Sec. 438.50(d)(3), children with serious emotional
disturbances, individuals with disabling mental disorders, individuals
with serious and complex medical conditions, and individuals with
physical and or mental disabilities that prevent them from performing
one or more activities of daily living. Further, we deleted the
reference to Sec. 438.50(d)(1) for individuals entitled to Medicare
benefits as these individuals are already exempt individuals who cannot
be required to enroll in benchmark or benchmark-equivalent plans
because of the requirement in section 1937(a)(2)(iii) of the Act.
We revised paragraph (h) of Sec. 440.315 to clarify that exempt
individuals include ``an individual with respect to whom child welfare
services are made available under part B of title IV to children in
foster care and individuals with respect to whom adoption or foster
care assistance is made available under part E of title IV, without
regard to age.''
We have revised paragraph (i) at Sec. 440.315 to state that
parents and caretaker relatives whom States are required to cover under
section 1931 of the Act, are considered exempt individuals. This
provision reverses the prior rule which limited the exemption to
individuals who were eligible for Medicaid based on the eligibility for
TANF; eligibility for Medicaid is not based, under Federal laws, on
eligibility for TANF.
We added a new paragraph (m) in Sec. 440.315 to include medically
needy or those eligible as a result of a reduction of countable income
based on costs incurred for medical care in the list of populations who
are exempt from mandatory enrollment in benchmark or benchmark-
equivalent plans.
[[Page 23097]]
Section 440.320 State Plan Requirements: Optional Enrollment for Exempt
Individuals
We revised paragraphs (a)(1), (a)(2), and (a)(3) at Sec. 440.320
to require that a State that chooses to offer enrollment in a benchmark
or benchmark-equivalent plan to exempt individuals must effectively
inform such individuals prior to enrollment that the individual is
exempt and that enrollment is voluntary. The State must inform the
individual of the benefits in the benchmark or benchmark-equivalent
plan and provide a comparison of how they differ from traditional
Medicaid State plan coverage, and document in the individual's
eligibility file that prior to enrollment the beneficiary was provided
a comparison of the benchmark or benchmark-equivalent benefit package
to the State plan package, was given ample time to make an informed
choice as to enrollment and voluntarily choose to enroll in the
benchmark or benchmark-equivalent plan.
We added a new paragraph (a)(4) to clarify that States must comply
with the requirements of Sec. 440.320(a)(1), (a)(2), and (a)(3) within
30 days after a determination is made that an individual has become
part of an exempt group while enrolled in benchmark or benchmark-
equivalent coverage.
We added new paragraphs (b)(1) and (b)(2) in Sec. 440.320 to
clarify the disenrollment process for exempt individuals and require
that States act upon disenrollment requests promptly for those exempt
individuals who choose to disenroll from benchmark or benchmark-
equivalent coverage and to require that the State have a process in
place to ensure continuous access to all standard State plan services
while requests to disenroll from benchmark or benchmark-equivalent
coverage are being processed. States must also maintain data to track
the number of exempt individuals who enroll in, and dissenroll from
benchmark or benchmark-equivalent plans.
Benchmark-Equivalent Health Benefits Coverage (Sec. 440.335)
We revised paragraph (b) in Sec. 440.335, which lists the
mandatory services that benchmark-equivalent plans must provide. In the
December 3, 2008 final rule, emergency services was included in the
description of other appropriate preventive services designated by the
Secretary. To clarify that benchmark equivalent coverage must include
emergency services we made emergency services a separate and distinct
requirement in paragraph (b)(5) and renumbered the paragraph relating
to preventive services as (b)(6) in Sec. 440.335. We also added family
planning services and supplies to the description of required
preventive services.
Actuarial Report for Benchmark-Equivalent Coverage (Sec. 440.340)
We revised Sec. 440.340(b)(7) to require States to take into
account the impact of cost sharing limitations when calculating
actuarial equivalency.
EPSDT Services Requirement (Sec. 440.345)
We revised paragraph (a) in Sec. 440.345 to reflect the new
requirements in CHIPRA to cover 19 and 20 year olds for full EPSDT
services. This section requires that ``The State must assure access to
early and periodic screening, diagnostic and treatment (EPSDT) services
through benchmark or benchmark-equivalent plan benefits or as
additional benefits to those plans for any child under 21 years of age
eligible under the State plan in a category under section
1902(a)(10)(A) of the Act.''
We removed the term ``wrap-around'' and replaced it with
``additional'' in paragraphs (a)(1) and (a)(2) in Sec. 440.345 of this
regulation, and the words ``through wrap-around,'' and replaced them
with ``additional'' in Sec. 440.345(b) of this regulation. We have
also revised the ``sufficiency'' provision. Together these
modifications are intended to make it clear that EPSDT services must in
all circumstances be provided by the State Medicaid program; either
through the benchmark or benchmark-equivalent plan or as an
``additional'' service. We have also added a statutory cite ``under
section 1937 of the Act'' after the word ``benefits'' in Sec.
440.345(b) of this regulation.
Employer-Sponsored Insurance Health Plans (Sec. 440.350)
We removed the language ``the additional or wrap-around'' and
replaced it with ``additional'' in Sec. 440.350(a) of this regulation.
We replaced the term ``cost-effectiveness'' with ``economy and
efficiency'' in Sec. 440.350(b) of this regulation to be consistent
with the new section heading of Sec. 440.370.
State Plan Requirement for Providing Additional Services (Sec.
440.360)
We removed the term ``wrap-around'' in the section heading in Sec.
440.360 of this regulation. We also revised Sec. 440.360 by removing
the language ``or wrap-around''.
Economy and Efficiency (Sec. 440.370)
We removed the section heading ``Cost-effectiveness'' and replaced
it with ``Economy and efficiency'' in Sec. 440.370 of this regulation.
Comparability (Sec. 440.375)
We removed the section heading ``Comparability and scope of
coverage'' and replaced it with ``Comparability'' in Sec. 440.370 of
this regulation. We also revised Sec. 440.375 by removing the language
``or requirements relating to the scope of coverage other than those
contained in this subpart''.
Delivery of Benchmark and Benchmark-Equivalent Coverage Through Managed
Care Entities (Sec. 440.385)
We replaced the title ``Freedom of choice'' with ``Delivery of
benchmark and benchmark-equivalent coverage through managed care
entities.'' We revised this section by removing the option to provide
benchmark or benchmark-equivalent benefit plans without regard to the
requirements for freedom of choice in Sec. 431.51 of this chapter.
Section 611(a) of CHIPRA clarified that benchmark and benchmark
equivalent plans must comply with all requirements of title XIX other
than 1902(a)(1) and 1902(a)(10)(B). We therefore revised the title and
text of 440.385 to provide that States wishing to deliver benchmark and
benchmark-equivalent benefit packages through a managed care entity may
do so but must comply with the requirements of section 1932 of the Act
and 42 CFR part 438.
Assurance of Transportation (Sec. 440.390)
We revised Sec. 440.390 to specify that if a benchmark or
benchmark-equivalent plan does not include transportation to and from
medically necessary covered Medicaid services, the State must
nevertheless assure that emergency and non-emergency transportation is
covered for beneficiaries enrolled in the benchmark and benchmark-
equivalent plan, as required under Sec. 431.53 of this chapter.
V. Collection of Information Requirements
The following requirements are subject to the Paperwork Reduction
Act (PRA). While some elements contained in the sections listed below
are approved under OMB control number 0938-0993, the current
information collection will need to be revised to reflect changes
contained in this final rule. CMS is revising this PRA package to make
necessary updates and to incorporate any new requirements not currently
approved by OMB. The revised package will be published in a
[[Page 23098]]
60-day Federal Register notice seeking public comment.
Section 440.320 State Plan Requirements: Optional Enrollment for Exempt
Individuals
Section 440.320(a) requires a State to: (1) Inform the individuals
that the enrollment is voluntary and that the individual may disenroll
from the benchmark or benchmark-equivalent coverage at any time and
regain immediate access to standard full Medicaid coverage under the
State plan; (2) Inform the exempt individual of the benefits available
under the benchmark or benchmark-equivalent benefit package and provide
a comparison of how they differ from the benefits available under the
standard full Medicaid program; and, (3) Document in the exempt
individual's eligibility file that the individual was informed in
accordance with this section and voluntarily chose to enroll in the
benchmark or benchmark-equivalent benefit package.
Section 440.330 Benchmark Health Benefits Coverage
Section 440.330(d) requires States wishing to opt for Secretarial-
approved coverage to submit a full description of the proposed coverage
and include a benefit-by-benefit comparison of the proposed plan to one
or more of the three other benchmark plans specified.
Section 440.340 Actuarial Report for Benchmark-Equivalent Coverage
Section 440.340 requires a State trying to obtain approval for
benchmark-equivalent health benefits coverage described in Sec.
440.335 to submit, as part of its State Plan Amendment, an actuarial
report. The report must provide sufficient detail to explain the basis
of the methodologies used to estimate the actuarial value or, if
requested by CMS, to replicate the State's result.
Section 440.345 Requirement To Provide EPSDT Services
Section 440.345(a)(2) requires a State to include a description in
their State Plan of how the additional services will be provided to
ensure that all individuals under 21 receive full EPSDT services. The
description must describe the populations covered and the procedures
for assuring those services.
Section 440.350 Employer-Sponsored Insurance Health Plans
Section 440.350(b) requires a State to set forth in the State plan
the criteria it will use to identify individuals who would be required
to enroll in an available group health plan to receive benchmark or
benchmark-equivalent coverage.
Section 440.360 State Plan Requirement for Providing Additional
Services
This section requires States opting to provide additional services
to the benchmark-equivalent plans, to describe the populations covered
and the payment methodology for these services in their State plan.
Section 440.390 Assurance of Transportation
A State must assure medically necessary transportation for
beneficiaries enrolled in a benchmark or benchmark-equivalent plan even
if transportation is not a service provided in the benchmark or
benchmark-equivalent plan.
VI. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993), the
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354),
section 1102(b) of the Act, section 202 of the Unfunded Mandates Reform
Act of 1995 (Pub. L. 104-4), Executive Order 13132 on Federalism
(August 4, 1999), and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). A regulatory impact
analysis (RIA) must be prepared for rules with economically significant
effects of $100 million or more in any 1 year. As a result, since there
is an economic impact of more than $100 million in any 1 year, this
final rule is categorized as economically significant and thus is
consequentially a major rule under the Congressional Review Act.
The regulatory impact analysis in this final rule incorporates
provisions of the Children's Health Insurance Program Authorization Act
(CHIPRA) of 2009, enacted on February 4, 2009, which corrected language
in the DRA and subsequently amended section 1937 ``State Flexibility
for Medicaid Benefit Packages.'' In addition, this final rule
incorporates provisions of the American Recovery and Reinvestment Act
(ARRA) of 2009 related to the temporary increase in the Federal
matching percentage (FMAP) for Medicaid, enacted on February 17, 2009.
The estimated aggregate Federal savings for fiscal years 2006 through
2014, as shown in Table 1, is estimated to be $4.97 billion. Also, the
estimated aggregate State savings for fiscal years 2006 through 2014,
as shown in Table 2, is $3.36 billion.
In the December 3, 2008 ``final rule,'' we estimated aggregate
impacts for fiscal years 2006 through 2010 of $2.28 billion in Federal
savings and $1.72 billion in State savings. In this final rule, the
updated aggregate impacts, for the same time period of fiscal years
2006 through 2010, are $1.84 billion in Federal savings and $1.05 in
State savings. As a result, relative to the December 3, 2008 final
rule, this yields a reduction in the aggregate impacts of $440 million
in Federal savings and $670 million in State savings, for fiscal years
2006 through 2010. We estimated the impact of this rule by analyzing
the potential Federal savings related to lower per capita spending that
may be achieved if States choose to enroll beneficiaries in eligible
populations in plans that are less costly than projected Medicaid
costs. To do this, we developed estimates based on the following
assumptions:
The number of eligible beneficiaries and the Federal
Medicaid costs of these beneficiaries are based on 2003 Medicaid
Statistical Information System (MSIS) data;
Projections of the number of eligible beneficiaries and
their associated Federal Medicaid costs were made using assumptions
from the President's Budget 2007, including enrollment growth rates and
per capita spending growth rates;
The relative costs of the new plans allowed under this
rule to current Medicaid spending were estimated based on reviews of
Medicaid spending data and the plans described in this rule.
Additionally, we have assumed that not all States would immediately use
the options made available through this rule; therefore, we assume that
State use of these plans will continue to increase through 2011. We
assumed that use in 2006 will be about 10 percent of 2011-level of use;
40 percent in 2007; 60 percent in 2008; 80 percent in 2009; and 90
percent in 2010. We do not assume any further expansion beyond 2011.
These estimates assume that there will be a negligible impact on
State administration costs. As States already have experience in
dealing with alternative plan designs, including through waivers or
managed care plans, we assumed States are equipped to
[[Page 23099]]
implement these plans and will be part of their normal administrative
spending.
Also, these estimates are subject to a substantial amount of
uncertainty and actual experience may be significantly different. The
range of possible experience is greater than under most other rules for
the following two reasons. First, this rule provides the option for
States to use alternative plans; to the extent that States participate
more or less than assumed here (both the number of States that
participate and the extensiveness of States' use of these plans),
Federal savings may be greater than or less than estimated. Second,
this rule also provides a wide range of options for States in designing
these plans; to the extent that States use plans that are relatively
more or less costly than assumed here, Federal savings may be less than
or greater than estimated.
Table 1--Estimated Annual Federal Savings Discounted at 0 Percent, 3 Percent and 7 Percent--From FY 2006 to FY 2014
[In $millions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total savings
Discount rate 2006 2007 2008 2009 2010 2011 2012 2013 2014 2006-2014
--------------------------------------------------------------------------------------------------------------------------------------------------------
0%..................................................... $50 $210 $340 $570 $670 $710 $740 $810 $870 $4,970
3%..................................................... 49 198 311 506 578 595 602 639 667 4,145
7%..................................................... 47 183 278 435 478 473 461 471 473 3,299
--------------------------------------------------------------------------------------------------------------------------------------------------------
We anticipate that States will phase in alternative benefit
programs, and changes will not be fully realized until 2010. The
majority of savings will be achieved through cost avoidance of future
anticipated costs by providing appropriate benefits based on a
population's health care needs, appropriate utilization of services,
and through gains in efficiencies through contracting. States will be
able to take greater advantage of marketplace dynamics within their
State. We also anticipate that a number of States will use this
flexibility to create programs that are more similar to their CHIP
programs. Because States are no longer tied to statewideness and
comparability rules for individuals who are not disabled, not aged, or
not blind, they will be able to offer individuals and families
different types of plans consistent with their needs and available
delivery systems.
Table 2--Estimated Annual State Savings Discounted at 0 Percent, 3 Percent and 7 Percent--From FY 2006 to FY 2014
[In $millions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total savings
Discount rate 2006 2007 2008 2009 2010 2011 2012 2013 2014 2006-2014
--------------------------------------------------------------------------------------------------------------------------------------------------------
0%..................................................... $40 $160 $250 $280 $320 $480 $560 $610 $660 $3,360
3%..................................................... 39 151 229 249 276 402 455 482 506 2,788
7%..................................................... 37 140 204 214 228 320 349 355 359 2,206
--------------------------------------------------------------------------------------------------------------------------------------------------------
The RFA requires agencies to analyze options for regulatory relief
of small businesses, if a rule has a significant impact on a
substantial number of small entities. For purposes of the RFA, small
entities as that term is used in the RFA (include small businesses,
nonprofit organizations, and small governmental jurisdictions). The
great majority of hospitals and most other health care providers and
suppliers are small entities, either by being nonprofit organizations
or by meeting the SBA definition of a small business (having revenues
of less than $7 million to $34.5 million in any 1 year). (For details,
see the Small Business Administration's final rule that set forth size
standards for health care industries, at 65 FR 69432, November 17,
2000.) Individuals and States are not included in the definition of a
small entity. The Secretary has determined that this provision applies
to States only and will not affect small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis, if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a metropolitan
statistical area and has fewer than 100 beds. The Secretary has
determined that this rule would not have a significant impact on the
operations of a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA)
(Pub. L. 104-4) also requires that agencies assess anticipated costs
and benefits before issuing any rule whose mandates require spending in
any 1 year of $100 million in 1995 dollars, updated annually for
inflation. In 2010, that threshold is approximately $135 million.
Because this rule does not mandate State participation in using these
benchmark plans, there is no obligation for the State to make any
change to their Medicaid program. As a result, there is no mandate for
the State. Therefore, we estimate this final will not mandate
expenditures in the threshold amount of $135 million in any 1 year.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. This final rule will not impose direct cost on States or
local governments or preempt State law. The rule will provide States
the option to implement alternative Medicaid benefits through a
Medicaid State plan amendment.
Comment: One commenter questioned the validity of CMS's Regulatory
Impact Analysis, believing that the proposed rule will cause additional
administrative effort in order for American Indians/Alaska Natives
beneficiaries to participate.
[[Page 23100]]
Response: CMS is required by Executive Order 12866 (September 1993,
Regulatory Planning and Review), the Regulatory Flexibility Act (RFA)
(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Act, the
Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive
Order 13132 on Federalism, and the Congressional Review Act (5 U.S.C.
804(2)) to conduct a regulatory analysis of the impact of any
regulatory revision to the Medicare, Medicaid, and/or Children's Health
Insurance Program before adoption of any rule. A Regulatory Impact
Analysis was completed for this rule. We believe there is negligible
impact on State administrative costs since States already have
experience in dealing with alternative plan designs, including through
waivers or managed care plans. Thus, we have assumed States are
equipped to implement these plans and that costs will be part of their
normal administrative spending. We believe this would be true for any
State that chooses to offer benchmark or benchmark-equivalent plans to
the Medicaid beneficiaries including American Indians/Alaska Natives
Medicaid beneficiaries.
B. Anticipated Effects
Before section 6044 of the DRA became effective on March 31, 2006,
State Medicaid programs generally were required to offer at minimum the
same standard benefit package to each individual, regardless of income,
eligibility category, or geographic location. Some States offered
alternative benefit packages to certain individuals under section 1115
demonstration waivers approved by the Centers for Medicare & Medicaid
Services. This provision allows for similar program alternatives under
the State plan. Without a waiver, States may form larger pools by
combining Medicaid individuals with their public employees.
C. Alternatives Considered
This rule finalizes requirements for States to elect alternative
Medicaid benefit programs through the adoption of a Medicaid State plan
amendment. The final requirements in this rule were designed to permit
State flexibility while assuring that beneficiaries will get quality
care that meets their needs. Under this rule, we will allow States to
define the alternative benefit packages by reference to the benchmark
or benchmark-equivalent standard, while making it clear that children
under 21 are eligible for the full range of Medicaid benefits under
EPSDT. We will also permit States to combine an alternative benefit
package with alternative benefit delivery methods, such as through
managed care or employer-based coverage, although compliance with all
Medicaid rules other than comparability or statewideness is required
unless directly contrary to this statute. An alternative might have
been to require the State to document any deviation from otherwise
applicable State plan requirements, much as is required under section
1115 demonstration waivers, 1915(b) waivers, 1915(c) waivers, or any
combination thereof. We have not elected this alternative because it
would be cumbersome for States, it will not be consistent with the
statutory use of benchmark and benchmark-equivalent coverage as
reference points for permissible benefit packages, and it will not
improve the clarity of the State plan. Another alternative might have
been to limit State flexibility under this provision to variation in
the amount, duration and scope of benefits without providing authority
for an integrated approach combining alternative benefits with
alternative benefit delivery methods. We have not elected this
alternative because an integrated approach allows greater State
flexibility to tailor both benefits and delivery methods to the
eligible groups of individuals being served.
D. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 3 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this rule. This table
provides our best estimate of the decrease in Medicaid payments as a
result of the changes presented in this rule. All savings are
classified as transfers to the Federal Government, as well as to
States.
Table 3--Accounting Statement: Classification of Estimated Expenditures, From FY 2006 to FY 2014
[In $millions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Transfers
--------------------------------------------------------------------------------------------------------
Category Units discount rate
Year dollar ------------------------------------------------ Period covered
7% 3% 0%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Annualized Monetized Transfers................. 2006 -$506.3 -$532.3 -$552.22 FYs 2006-2014
--------------------------------------------------------------------------------------------------------------------------------------------------------
From Whom To Whom?............................. Federal Government to beneficiaries, providers
--------------------------------------------------------------------------------------------------------------------------------------------------------
Annualized Monetized Transfers................. 2006 -338.5 -358.1 -373.33 FYs 2006-2014
--------------------------------------------------------------------------------------------------------------------------------------------------------
From Whom to Whom?............................. State Governments to beneficiaries, providers
--------------------------------------------------------------------------------------------------------------------------------------------------------
Column 1: Category--Contains the description of the different
impacts of the rule; it could include monetized, quantitative but not
monetized, or qualitative but not quantitative or monetized impacts; it
also may contain unit of measurement (such as, dollars). In this case,
the Federal and State annualized monetized impacts of the rule are
presented.
Column 2: Year Dollar--Contains the year to which dollars are
normalized; that is, the first year that dollars are discounted in the
estimate.
Column 3: Unit Discount Rate--Contains the discount rate or rates
used to estimate the annualized monetized impacts. In this case, three
rates are used: 7 percent; 3 percent; 0 percent.
Column 4: Primary Estimate--Contains the quantitative or
qualitative impact of the rule for the respective category of impact.
Monetized amounts are generally shown in real dollar terms. In this
case, the federalized annualized monetized primary estimate represents
the equivalent amount that, if paid (saved) each year over the period
covered, would result in the same net
[[Page 23101]]
present value of the stream of costs (savings) estimated over the
period covered.
Column 5: Period Covered--Contains the years for which the estimate
was made.
Rows: The rows contain the estimates associated with each specific
impact and each discount rate used.
Estimated Savings--The following table shows the discounted costs
(savings) for each discount rate over the period covered. The monetized
figures represent the net present value of the impact in the year the
rule takes effect. These numbers represent the anticipated annual
reduction in Federal and State Medicaid spending under this rule.
``From Whom to Whom?''--In the case of a transfer (as opposed to a
change in aggregate social welfare as described in the OMB Circular),
this section describes the parties involved in the transfer of costs.
In this case, the expenditures represent a reduction in Federal and
State governments spending on behalf of beneficiaries.
E. Conclusion
We estimate that the use of benchmark plans under this rule will
result in total Federal savings of $4.97 billion and State savings of
$3.36 billion for fiscal years 2006 through 2014. This translates to an
annualized Federal savings of $506.3 million and $532.3 million at the
7 percent and 3 percent discount rates. Also, this yields an annualized
State savings of $338.5 million and $358.1 million at the 7 percent and
3 percent discount rates over the same time period of fiscal years 2006
through 2014. These savings would arise as States use the plans
described by this rule to manage the costs of their Medicaid program by
modifying plan benefits for targeted beneficiaries. The actual savings
will heavily depend on the number of States that ultimately implement
these plans, the number of beneficiaries States cover with these plans,
and the specific design and selection of benchmark plans.
For reasons stated above, we are not preparing analyses for either
the RFA or section 1102(b) of the Act because we have determined that
this rule will not have a significant economic impact on a substantial
number of small entities or a significant impact on the operations of a
substantial number of small rural hospitals.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 440
Grant programs--health, Medicaid.
0
For the reasons set forth in the preamble, the Centers for Medicare &
Medicaid Services amends 42 CFR chapter IV as set forth below:
PART 440--SERVICES: GENERAL PROVISIONS
0
1. The authority citation for part 440 continues to read as follows:
Authority: Sec. 1102 of the Social Security Act (42
U.S.C.1302).
0
2. Subpart C, consisting of Sec. 440.300 through Sec. 440.390, is
revised to read as follows:
Subpart C--Benchmark Benefit and Benchmark-Equivalent Coverage
Sec.
440.300 Basis.
440.305 Scope.
440.310 Applicability.
440.315 Exempt individuals.
440.320 State plan requirements: Optional enrollment for exempt
individuals.
440.325 State plan requirements: Coverage and benefits.
440.330 Benchmark health benefits coverage.
440.335 Benchmark-equivalent health benefits coverage.
440.340 Actuarial report for benchmark-equivalent coverage.
440.345 EPSDT services requirement.
440.350 Employer-sponsored insurance health plans.
440.355 Payment of premiums.
440.360 State plan requirement for providing additional services.
440.365 Coverage of rural health clinic and federally qualified
health center (FQHC) services.
440.370 Economy and efficiency.
440.375 Comparability.
440.380 Statewideness.
440.385 Delivery of benchmark and benchmark-equivalent coverage
through managed care entities.
440.390 Assurance of transportation.
Subpart C--Benchmark Benefit and Benchmark-Equivalent Coverage
Sec. 440.300 Basis.
This subpart implements section 1937 of the Act, which authorizes
States to provide for medical assistance to one or more groups of
Medicaid-eligible individuals, specified by the State under an approved
State plan amendment, through enrollment in coverage that provides
benchmark or benchmark-equivalent health care benefit coverage.
Sec. 440.305 Scope.
(a) General. This subpart sets out requirements for States that
elect to provide medical assistance to certain Medicaid eligible
individuals within one or more groups of individuals specified by the
State, through enrollment of the individuals in coverage, identified as
``benchmark'' or ``benchmark-equivalent.''
(b) Limitations. A State may only apply the option in paragraph (a)
of this section for an individual whose eligibility is based on an
eligibility category under section 1905(a) of the Act that could have
been covered under the State's plan on or before February 8, 2006.
(c) A State may not require but may offer enrollment in benchmark
or benchmark-equivalent coverage to the Medicaid eligible individuals
listed in Sec. 440.315. States allowing individuals to voluntarily
enroll must be in compliance with the rules specified at Sec. 440.320.
(d) Prior to submitting to the Centers for Medicare and Medicaid
Services for approval a State plan amendment to establish a benchmark
or benchmark-equivalent benefit plan or an amendment to substantially
modify an existing benchmark or benchmark-equivalent benefit plan, a
State must have provided the public with advance notice of the
amendment and reasonable opportunity to comment with respect to such
amendment, and have included in the notice a description of the method
for assuring compliance with Sec. 440.345 of this subpart related to
full access to EPSDT services, and the method for complying with the
provisions of section 5006(e) of the American Recovery and Reinvestment
Act of 2009.
Sec. 440.310 Applicability.
(a) Enrollment. The State may require ``full benefit eligible''
individuals not excluded in Sec. 440.315 to enroll in benchmark or
benchmark-equivalent coverage.
(b) Full benefit eligible. An individual is a full benefit eligible
if determined by the State to be eligible to receive the standard full
Medicaid benefit package under the approved State plan if not for the
application of the option available under this subpart.
Sec. 440.315 Exempt individuals.
Individuals within one (or more) of the following categories are
exempt from mandatory enrollment in benchmark or benchmark-equivalent
coverage.
(a) The individual is a pregnant woman who is required to be
covered under the State plan under section 1902(a)(10)(A)(i) of the
Act.
(b) The individual qualifies for medical assistance under the State
plan on the basis of being blind or disabled (or being treated as being
blind or disabled) without regard to whether the
[[Page 23102]]
individual is eligible for Supplemental Security Income benefits under
title XVI on the basis of being blind or disabled and including an
individual who is eligible for medical assistance on the basis of
section 1902(e)(3) of the Act.
(c) The individual is entitled to benefits under any part of
Medicare.
(d) The individual is terminally ill and is receiving benefits for
hospice care under title XIX.
(e) The individual is an inpatient in a hospital, nursing facility,
intermediate care facility for the mentally retarded, or other medical
institution, and is required, as a condition of receiving services in
that institution under the State plan, to spend for costs of medical
care all but a minimal amount of the individual's income required for
personal needs.
(f) The individual is medically frail or otherwise an individual
with special medical needs. For these purposes, the State's definition
of individuals who are medically frail or otherwise have special
medical needs must at least include those individuals described in
Sec. 438.50(d)(3) of this chapter, children with serious emotional
disturbances, individuals with disabling mental disorders, individuals
with serious and complex medical conditions, and individuals with
physical and/or mental disabilities that significantly impair their
ability to perform one or more activities of daily living.
(g) The individual qualifies based on medical condition for medical
assistance for long-term care services described in section
1917(c)(1)(C) of the Act.
(h) The individual is an individual with respect to whom child
welfare services are made available under part B of title IV to
children in foster care and individuals with respect to whom adoption
or foster care assistance is made available under part E of title IV,
without regard to age.
(i) The individual is a parent or caretaker relative whom the State
is required to cover under section 1931 of the Act.
(j) The individual is a woman who is receiving medical assistance
by virtue of the application of sections 1902(a)(10)(ii)(XVIII) and
1902(aa) of the Act.
(k) The individual qualifies for medical assistance on the basis of
section 1902(a)(10)(A)(ii)(XII) of the Act.
(l) The individual is only covered by Medicaid for care and
services necessary for the treatment of an emergency medical condition
in accordance with section 1903(v) of the Act.
(m) The individual is determined eligible as medically needy or
eligible because of a reduction of countable income based on costs
incurred for medical or other remedial care under section 1902(f) of
the Act or otherwise based on incurred medical costs.
Sec. 440.320 State plan requirements: Optional enrollment for exempt
individuals.
(a) General rule. A State plan that offers exempt individuals as
defined in Sec. 440.315 the option to enroll in benchmark or
benchmark-equivalent coverage must identify in its State plan the
exempt groups for which this coverage is available, and must comply
with the following provisions:
(1) In any case in which the State offers an exempt individual the
option to obtain coverage in a benchmark or benchmark-equivalent
benefit package, the State must effectively inform the individual prior
to enrollment that the enrollment is voluntary and that the individual
may disenroll from the benchmark or benchmark-equivalent coverage at
any time and regain immediate access to standard full Medicaid coverage
under the State plan.
(2) Prior to any enrollment in benchmark or benchmark-equivalent
coverage, the State must inform the exempt individual of the benefits
available under the benchmark or benchmark-equivalent benefit package
and the costs under such a package and provide a comparison of how they
differ from the benefits and costs available under the standard full
Medicaid program. The State must also inform exempt individuals that
they may disenroll at any time and provide them with information about
the process for disenrolling.
(3) The State must document in the exempt individual's eligibility
file that the individual was informed in accordance with this section
prior to enrollment, was given ample time to arrive at an informed
choice, and voluntarily and affirmatively chose to enroll in the
benchmark or benchmark-equivalent benefit package.
(4) For individuals who the State determines have become exempt
individuals while enrolled in benchmark or benchmark-equivalent
coverage, the State must comply with the requirements in paragraphs
(a)(1) through (a)(3) of this section above within 30 days after such
determination.
(b) Disenrollment Process. (1) The State must act upon requests
promptly for exempt individuals who choose to disenroll from benchmark
or benchmark-equivalent coverage.
(2) The State must have a process in place to ensure that exempt
individuals have access to all standard State plan services while
disenrollment requests are being processed.
(3) The State must maintain data that tracks the total number of
beneficiaries that have voluntarily enrolled in a benchmark plan and
the total number of individuals that have disenrolled from the
benchmark plan.
Sec. 440.325 State plan requirements: Coverage and benefits.
Subject to requirements in Sec. 440.345 and Sec. 440.365, States
may elect to provide any of the following types of health benefits
coverage:
(a) Benchmark coverage in accordance with Sec. 440.330.
(b) Benchmark-equivalent coverage in accordance with Sec. 440.335.
Sec. 440.330 Benchmark health benefits coverage.
Benchmark coverage is health benefits coverage that is equal to the
coverage under one or more of the following benefit plans:
(a) Federal Employees Health Benefit Plan Equivalent Coverage
(FEHBP--Equivalent Health Insurance Coverage). A benefit plan
equivalent to the standard Blue Cross/Blue Shield preferred provider
option service benefit plan that is described in and offered to Federal
employees under 5 U.S.C. 8903(1).
(b) State employee coverage. Health benefits coverage that is
offered and generally available to State employees in the State.
(c) Health maintenance organization (HMO) plan. A health insurance
plan that is offered through an HMO, (as defined in section 2791(b)(3)
of the Public Health Service Act) that has the largest insured
commercial, non-Medicaid enrollment in the State.
(d) Secretary-approved coverage. Any other health benefits coverage
that the Secretary determines, upon application by a State, provides
appropriate coverage to meet the needs of the population provided that
coverage. States wishing to elect Secretarial approved coverage should
submit a full description of the proposed coverage, (including a
benefit-by-benefit comparison of the proposed plan to one or more of
the three other benchmark plans specified above or to the State's
standard full Medicaid coverage package under section 1905(a) of the
Act), and of the population to which the coverage would be offered. In
addition, the State should submit any other information that would be
relevant to a determination that the proposed health benefits coverage
would be appropriate for the proposed population. The scope
[[Page 23103]]
of a Secretary-approved health benefits package will be limited to
benefits within the scope of the categories available under a benchmark
coverage package or the standard full Medicaid coverage package under
section 1905(a) of the Act.
Sec. 440.335 Benchmark-equivalent health benefits coverage.
(a) Aggregate actuarial value. Benchmark-equivalent coverage is
health benefits coverage that has an aggregate actuarial value, as
determined under Sec. 440.340, that is at least actuarially equivalent
to the coverage under one of the benchmark benefit packages described
in Sec. 440.330 for the identified Medicaid population to which it
will be offered.
(b) Required coverage. Benchmark-equivalent health benefits
coverage must include coverage for the following categories of
services:
(1) Inpatient and outpatient hospital services.
(2) Physicians' surgical and medical services.
(3) Laboratory and x-ray services.
(4) Well-baby and well-child care, including age-appropriate
immunizations.
(5) Emergency services.
(6) Family planning services and supplies and other appropriate
preventive services, as designated by the Secretary.
(c) Additional coverage. (1) In addition to the categories of
services of this section, benchmark-equivalent coverage may include
coverage for any additional services in a category included in the
benchmark plan or described in section 1905(a) of the Act.
(2) If the benchmark coverage package used by the State for
purposes of comparison in establishing the aggregate actuarial value of
the benchmark-equivalent package includes any of the following four
categories of services: Prescription drugs; mental health services;
vision services; and hearing services; then the actuarial value of the
coverage for each of these categories of service in the benchmark-
equivalent coverage package must be at least 75 percent of the
actuarial value of the coverage for that category of service in the
benchmark plan used for comparison by the State.
(3) If the benchmark coverage package does not cover one of the
four categories of services in paragraph (c)(2) of this section, then
the benchmark-equivalent coverage package may, but is not required to,
include coverage for that category of service.
Sec. 440.340 Actuarial report for benchmark-equivalent coverage.
(a) A State plan amendment that would provide for benchmark-
equivalent health benefits coverage described in Sec. 440.335, must
include an actuarial report. The actuarial report must contain an
actuarial opinion that the benchmark-equivalent health benefits
coverage meets the actuarial requirements set forth in Sec. 440.335.
The report must also specify the benchmark coverage used for
comparison.
(b) The actuarial report must state that it was prepared according
to the following requirements:
(1) By an individual who is a member of the American Academy of
Actuaries (AAA).
(2) Using generally accepted actuarial principles and methodologies
of the AAA.
(3) Using a standardized set of utilization and price factors.
(4) Using a standardized population that is representative of the
population involved.
(5) Applying the same principles and factors in comparing the value
of different coverage (or categories of services).
(6) Without taking into account any differences in coverage based
on the method of delivery or means of cost control or utilization used.
(7) Taking into account the ability of the State to reduce benefits
by considering the increase in actuarial value of health benefits
coverage offered under the State plan that results from the limitations
on cost sharing (with the exception of premiums) under that coverage.
(c) The actuary preparing the opinion must select and specify the
standardized set of factors and the standardized population to be used
in paragraphs (b)(3) and (b)(4) of this section.
(d) The State must provide sufficient detail to explain the basis
of the methodologies used to estimate the actuarial value or, if
requested by CMS, to replicate the State's result.
Sec. 440.345 EPSDT services requirement.
(a) The State must assure access to early and periodic screening,
diagnostic and treatment (EPSDT) services through benchmark or
benchmark-equivalent plan benefits or as additional benefits provided
by the State for any child under 21 years of age eligible under the
State plan in a category under section 1902(a)(10)(A) of the Act.
(1) Sufficiency. Any additional EPSDT benefits not provided by the
benchmark or benchmark-equivalent plan must be sufficient so that, in
combination with the benchmark or benchmark-equivalent benefits plan,
these individuals have access to the full EPSDT benefit.
(2) State Plan requirement. The State must include a description of
how the additional benefits will be provided, how access to additional
benefits will be coordinated and how beneficiaries and providers will
be informed of these processes in order to ensure that these
individuals have access to the full EPSDT benefit.
(b) [Reserved]
Sec. 440.350 Employer-sponsored insurance health plans.
(a) A State may provide benchmark or benchmark-equivalent coverage
by obtaining employer sponsored health plans (either alone or with
additional services covered separately under Medicaid) for individuals
with access to private health insurance.
(b) The State must assure that employer sponsored plans meet the
requirements of benchmark or benchmark-equivalent coverage, including
the economy and efficiency requirements at Sec. 440.370.
(c) A State may provide benchmark or benchmark-equivalent coverage
through a combination of employer sponsored health plans and additional
benefit coverage provided by the State that wraps around the employer
sponsored health plan which, in the aggregate, results in benchmark or
benchmark-equivalent level of coverage for those individuals.
Sec. 440.355 Payment of premiums.
Payment of premiums by the State, net of beneficiary contributions,
to obtain benchmark or benchmark-equivalent benefit coverage on behalf
of beneficiaries under this section will be treated as medical
assistance under section 1905(a) of the Act.
Sec. 440.360 State plan requirement for providing additional
services.
In addition to the requirements of Sec. 440.345 the State may
elect to provide additional coverage to individuals enrolled in
benchmark or benchmark-equivalent plans. The State plan must describe
the populations covered and the payment methodology for these services.
Additional services must be in categories that are within the scope of
the benchmark coverage, or are described in section 1905(a) of the Act.
Sec. 440.365 Coverage of rural health clinic and federally qualified
health center (FQHC) services.
If a State provides benchmark or benchmark-equivalent coverage to
individuals, it must assure that the individual has access, through
that
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coverage or otherwise, to rural health clinic services and FQHC
services as defined in subparagraphs (B) and (C) of section 1905(a)(2)
of the Act. Payment for these services must be made in accordance with
the payment provisions of section 1902(bb) of the Act.
Sec. 440.370 Economy and efficiency.
Benchmark and benchmark-equivalent coverage and any additional
benefits must be provided in accordance with Federal upper payment
limits, procurement requirements and other economy and efficiency
principles that would otherwise be applicable to the services or
delivery system through which the coverage and benefits are obtained.
Sec. 440.375 Comparability.
States have the option to amend their State plan to provide
benchmark or benchmark-equivalent coverage to individuals without
regard to comparability.
Sec. 440.380 Statewideness.
States have the option to amend their State plan to provide
benchmark or benchmark-equivalent coverage to individuals without
regard to statewideness.
Sec. 440.385 Delivery of benchmark and benchmark-equivalent coverage
through managed care entities.
In implementing benchmark or benchmark-equivalent benefit packages,
States must comply with the managed care provisions at section 1932 of
the Act and part 438 of this chapter, if benchmark and benchmark-
equivalent benefits are provided through a managed care entity.
Sec. 440.390 Assurance of transportation.
If a benchmark or benchmark-equivalent plan does not include
transportation to and from medically necessary covered Medicaid
services, the State must nevertheless assure that emergency and non-
emergency transportation is covered for beneficiaries enrolled in the
benchmark or benchmark-equivalent plan, as required under Sec. 431.53
of this chapter.
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
Dated: January 21, 2010.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: March 2, 2010.
Kathleen Sebelius,
Secretary.
[FR Doc. 2010-9734 Filed 4-29-10; 8:45 am]
BILLING CODE 4120-01-P