§ 1396u-7. State flexibility in benefit packages
(a)
State option of providing benchmark benefits
(1)
Authority
(A)
In general
Notwithstanding section
1396a
(a)(1) of this title (relating to statewideness), section
1396a
(a)(10)(B) of this title (relating to comparability) and any other provision of this subchapter which would be directly contrary to the authority under this section and subject to subsection [1] (E), a State, at its option as a State plan amendment, may provide for medical assistance under this subchapter to individuals within one or more groups of individuals specified by the State through coverage that—
(i)
provides benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2); and
(ii)
for any individual described in section
1396d
(a)(4)(B) of this title who is eligible under the State plan in accordance with paragraphs (10) and (17) of section
1396a
(a) of this title, consists of the items and services described in section
1396d
(a)(4)(B) of this title (relating to early and periodic screening, diagnostic, and treatment services defined in section
1396d
(r) of this title) and provided in accordance with the requirements of section
1396a
(a)(43) of this title.
(B)
Limitation
The State may only exercise the option under subparagraph (A) for an individual eligible under an eligibility category that had been established under the State plan on or before February 8, 2006.
(C)
Option of additional benefits
In the case of coverage described in subparagraph (A), a State, at its option, may provide such additional benefits as the State may specify.
(E)
Rule of construction
Nothing in this paragraph shall be construed as—
(i)
requiring a State to offer all or any of the items and services required by subparagraph (A)(ii) through an issuer of benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2);
(2)
Application
(A)
In general
Except as provided in subparagraph (B), a State may require that a full-benefit eligible individual (as defined in subparagraph (C)) within a group obtain benefits under this subchapter through enrollment in coverage described in paragraph (1)(A). A State may apply the previous sentence to individuals within 1 or more groups of such individuals.
(B)
Limitation on application
A State may not require under subparagraph (A) an individual to obtain benefits through enrollment described in paragraph (1)(A) if the individual is within one of the following categories of individuals:
(i)
Mandatory pregnant women
The individual is a pregnant woman who is required to be covered under the State plan under section
1396a
(a)(10)(A)(i) of this title.
(ii)
Blind or disabled individuals
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 individual is eligible for supplemental security income benefits under subchapter XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of section
1396a
(e)(3) of this title.
(iv)
Terminally ill hospice patients
The individual is terminally ill and is receiving benefits for hospice care under this subchapter.
(v)
Eligible on basis of institutionalization
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 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.
(vi)
Medically frail and special medical needs individuals
The individual is medically frail or otherwise an individual with special medical needs (as identified in accordance with regulations of the Secretary).
(vii)
Beneficiaries qualifying for long-term care services
The individual qualifies based on medical condition for medical assistance for long-term care services described in section
1396p
(c)(1)(C) of this title.
(viii)
Children in foster care receiving child welfare services and children receiving foster care or adoption assistance
The individual is an individual with respect to whom child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care or with respect to whom adoption or foster care assistance is made available under part E of such subchapter, without regard to age.
(ix)
TANF and section
1396u–1 parents
The individual qualifies for medical assistance on the basis of eligibility to receive assistance under a State plan funded under part A of subchapter IV (as in effect on or after the welfare reform effective date defined in section
1396u–1
(i) of this title).
(x)
Women in the breast or cervical cancer program
The individual is a woman who is receiving medical assistance by virtue of the application of sections
1396a
(a)(10)(A)(ii)(XVIII) and
1396a
(aa) of this title.
(xi)
Limited services beneficiaries
The individual—
(I)
qualifies for medical assistance on the basis of section
1396a
(a)(10)(A)(ii)(XII) of this title; or
(C)
Full-benefit eligible individuals
(i)
In general
For purposes of this paragraph, subject to clause (ii), the term “full-benefit eligible individual” means for a State for a month an individual who is determined eligible by the State for medical assistance for all services defined in section
1396d
(a) of this title which are covered under the State plan under this subchapter for such month under section
1396a
(a)(10)(A) of this title or under any other category of eligibility for medical assistance for all such services under this subchapter, as determined by the Secretary.
(ii)
Exclusion of medically needy and spend-down populations
Such term shall not include an individual determined to be eligible by the State for medical assistance under section
1396a
(a)(10)(C) of this title or by reason of section
1396a
(f) of this title or otherwise eligible based on a reduction of income based on costs incurred for medical or other remedial care.
(b)
Benchmark benefit packages
(1)
In general
For purposes of subsection (a)(1), each of the following coverages shall be considered to be benchmark coverage:
(B)
State employee coverage
A health benefits coverage plan that is offered and generally available to State employees in the State involved.
(2)
Benchmark-equivalent coverage
For purposes of subsection (a)(1), coverage that meets the following requirement shall be considered to be benchmark-equivalent coverage:
(A)
Inclusion of basic services
The coverage includes benefits for items and services within each of the following categories of basic services:
(B)
Aggregate actuarial value equivalent to benchmark package
The coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages described in paragraph (1).
(C)
Substantial actuarial value for additional services included in benchmark package
With respect to each of the following categories of additional services for which coverage is provided under the benchmark benefit package used under subparagraph (B), the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the coverage of that category of services in such package:
(3)
Determination of actuarial value
The actuarial value of coverage of benchmark benefit packages shall be set forth in an actuarial opinion in an actuarial report that has been prepared—
(E)
applying the same principles and factors in comparing the value of different coverage (or categories of services);
(F)
without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used; and
(G)
taking into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under this subchapter that results from the limitations on cost sharing under such coverage.
The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subparagraphs (C) and (D).
(4)
Coverage of rural health clinic and FQHC services
Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark equivalent coverage under this section unless—
(c)
Publication of provisions affected
With respect to a State plan amendment to provide benchmark benefits in accordance with subsections (a) and (b) that is approved by the Secretary, the Secretary shall publish on the Internet website of the Centers for Medicare & Medicaid Services, a list of the provisions of this subchapter that the Secretary has determined do not apply in order to enable the State to carry out the plan amendment and the reason for each such determination on the date such approval is made, and shall publish such list in the Federal Register and [2] not later than 30 days after such date of approval.
[1] So in original. Probably should be “subparagraph”.
[2] So in original.