42 U.S.C. § 1396u–7 | State flexibility in benefit packages

(a)

State option of providing benchmark benefits

(1)

Authority

(A)

In general

section 1396a(a)(1) of this title section 1396a(a)(10)(B) of this titleNotwithstanding (relating to statewideness), (relating to comparability) and any other provision of this subchapter which would be directly contrary to the authority under this section and subject to subparagraphs (E) and (F), 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)

section 1396d(a)(4)(B) of this title section 1396a(a) of this title section 1396d(a)(4)(B) of this title section 1396d(r) of this title section 1396a(a)(43) of this title for any individual described in who is eligible under the State plan in accordance with paragraphs (10) and (17) of , consists of the items and services described in (relating to early and periodic screening, diagnostic, and treatment services defined in ) and provided in accordance with the requirements of .

(B)

Limitation

section 1396a(a)(10)(A)(i) of this titleFebruary 8, 2006The State may only exercise the option under subparagraph (A) for an individual eligible under subclause (VIII) of or under an eligibility category that had been established under the State plan on or before .

(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.

(D)

Treatment as medical assistance

section 1396d(a) of this titlePayment of premiums for such coverage under this subsection shall be treated as payment of other insurance premiums described in the third sentence of .

(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);

(ii)

preventing a State from offering 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); or

(iii)

section 1396d of this title section 1396a(a)(43) of this title affecting a child’s entitlement to care and services described in subsections (a)(4)(B) and (r) of and provided in accordance with whether provided through benchmark coverage, benchmark equivalent coverage, or otherwise.

(F)

Necessary transportation

section 1396b(i)(9) of this title section 1396a(a)(4) of this titleNotwithstanding the preceding provisions of this paragraph, a State may not provide medical assistance through the enrollment of an individual with benchmark coverage or benchmark equivalent coverage described in subparagraph (A)(i) unless, subject to and in accordance with , the benchmark benefit package or benchmark equivalent coverage (or the State)—

(i)

ensures necessary transportation for individuals enrolled under such package or coverage to and from providers; and

(ii)

provides a description of the methods that will be used to ensure such transportation.

(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

section 1396a(a)(10)(A)(i) of this titleThe individual is a pregnant woman who is required to be covered under the State plan under .

(ii)

Blind or disabled individuals

section 1396a(e)(3) of this titleThe 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 .

(iii)

Dual eligibles

The individual is entitled to benefits under any part of subchapter XVIII.

(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

section 1396p(c)(1)(C) of this titleThe individual qualifies based on medical condition for medical assistance for long-term care services described in .

(viii)

Children in foster care receiving child welfare services and children receiving foster care or adoption assistance

section 1396a(a)(10)(A)(i)(IX) of this titleThe 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, or the individual qualifies for medical assistance on the basis of .

(ix)

TANF and section 1396u–1 parents

section 1396u–1(i) of this titleThe 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 ).

(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)

section 1396a(a)(10)(A)(ii)(XII) of this title qualifies for medical assistance on the basis of ; or

(II)

section 1641 of title 8 section 1396b(v) of this title is not a qualified alien (as defined in ) and receives care and services necessary for the treatment of an emergency medical condition in accordance with .

(C)

Full-benefit eligible individuals

(i)

In general

section 1396d(a) of this title section 1396a(a)(10)(A) of this titleFor 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 which are covered under the State plan under this subchapter for such month under 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

section 1396a(a)(10)(C) of this title section 1396a(f) of this titleSuch term shall not include an individual determined to be eligible by the State for medical assistance under or by reason of 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), subject to paragraphs (5) and (6), each of the following coverages shall be considered to be benchmark coverage:

(A)

FEHBP-equivalent health insurance coverage

section 8903(1) of title 5The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under .

(B)

State employee coverage

A health benefits coverage plan that is offered and generally available to State employees in the State involved.

(C)

Coverage offered through HMO

The health insurance coverage plan that—

(i)

section 300gg–91(b)(3) of this title is offered by a health maintenance organization (as defined in ), and

(ii)

has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State involved.

(D)

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 such coverage.

(2)

Benchmark-equivalent coverage

1 So in original. Probably should be followed by a comma.

For purposes of subsection (a)(1), subject to paragraphs (5) and (6)  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:

(i)

Inpatient and outpatient hospital services.

(ii)

Physicians’ surgical and medical services.

(iii)

Laboratory and x-ray services.

(iv)

Coverage of prescription drugs.

(v)

Mental health services.

(vi)

Well-baby and well-child care, including age-appropriate immunizations.

(vii)

Other appropriate preventive services, as designated by the Secretary.

(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:

(i)

Vision services.

(ii)

Hearing services.

(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—

(A)

by an individual who is a member of the American Academy of Actuaries;

(B)

using generally accepted actuarial principles and methodologies;

(C)

using a standardized set of utilization and price factors;

(D)

using a standardized population that is representative of the population involved;

(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—

(A)

section 1396d(a)(2) of this title the individual has access, through such coverage or otherwise, to services described in subparagraphs (B) and (C) of ; and

(B)

section 1396a(bb) of this title payment for such services is made in accordance with the requirements of .

(5)

Minimum standards

January 1, 2014section 18022(b) of this titleJanuary 1, 2022section 1396d(gg) of this titleEffective , any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) must provide at least essential health benefits as described in , and beginning , coverage of routine patient costs for items and services furnished in connection with participation in a qualifying clinical trial (as defined in ).

(6)

Mental health services parity

(A)

In general

section 300gg–26(a) of this title section 300gg–26(a) of this titleIn the case of any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) that is offered by an entity that is not a medicaid managed care organization and that provides both medical and surgical benefits and mental health or substance use disorder benefits, the entity shall ensure that the financial requirements and treatment limitations applicable to such mental health or substance use disorder benefits comply with the requirements of in the same manner as such requirements apply to a group health plan. In applying the previous sentence with respect to requirements under paragraph (8) of , a benchmark benefit package or benchmark equivalent coverage described in such sentence shall be treated as in compliance with such requirements if the State plan under this subchapter or the benchmark benefit package or benefit equivalent coverage, as applicable, is in compliance with subpart C of part 440 of title 42, Code of Federal Regulations, or any successor regulation.

(B)

Deemed compliance

section 1396d(a)(4)(B) of this title section 1396a(a)(10)(A) of this title section 1396d(a)(4)(B) of this title section 1396d(r) of this title section 1396a(a)(43) of this titleCoverage provided with respect to an individual described in and covered under the State plan under of the services described in (relating to early and periodic screening, diagnostic, and treatment services defined in ) and provided in accordance with , shall be deemed to satisfy the requirements of subparagraph (A).

(7)

Coverage of family planning services and supplies

section 1396d(a)(4)(C) of this titleNotwithstanding 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 such coverage includes for any individual described in , medical assistance for family planning services and supplies in accordance with such section.

(8)

COVID–19 vaccines, testing, and treatment

March 11, 2021section 1320b–5(g)(1)(B) of this titleNotwithstanding 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, during the period beginning on , and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in , such coverage includes (and does not impose any deduction, cost sharing, or similar charge for)—

(A)

COVID–19 vaccines and administration of the vaccines; and

(B)

testing and treatments for COVID–19, including specialized equipment and therapies (including preventive therapies), and, in the case of such an individual who is diagnosed with or presumed to have COVID–19, during the period such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID–19, if otherwise covered under the State plan (or waiver of such plan).

(c)

Publication of provisions affected

2 So in original.

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  not later than 30 days after such date of approval.

Aug. 14, 1935, ch. 531 Pub. L. 109–171, title VI, § 6044(a)Feb. 8, 2006120 Stat. 88 Pub. L. 111–3, title VI, § 611(a)Feb. 4, 2009123 Stat. 100 Pub. L. 111–148, title IIMar. 23, 2010124 Stat. 275 Pub. L. 116–260, div. BB, title II, § 203(a)(4)(B)Dec. 27, 2020134 Stat. 2917 Pub. L. 117–2, title IX, § 9811(a)(5)Mar. 11, 2021135 Stat. 211(, title XIX, § 1937, as added , , ; amended –(c), , , 101; , §§ 2001(a)(5)(E), (c), 2004(c)(2), 2303(c), , , 276, 283, 296; , div. CC, title II, §§ 209(a)(2), 210(c), , , 2986, 2991; , , .)

Editorial Notes

Prior Provisions

Aug. 14, 1935section 1396v of this titleA prior section 1937 of act , was renumbered section 1939 and is classified to .

Amendments

Pub. L. 117–22021—Subsec. (b)(8). added par. (8).

Pub. L. 116–260, § 209(a)(2)(A)2020—Subsec. (a)(1)(A). , substituted “subparagraphs (E) and (F)” for “subsection (E)”.

Pub. L. 116–260, § 209(a)(2)(B)Subsec. (a)(1)(F). , added subpar. (F).

Pub. L. 116–260, § 210(c)January 1, 2022section 1396d(gg) of this titleSubsec. (b)(5). , inserted “, and beginning , coverage of routine patient costs for items and services furnished in connection with participation in a qualifying clinical trial (as defined in )” before period at end.

Pub. L. 116–260, § 203(a)(4)(B)section 300gg–26(a) of this titleSubsec. (b)(6)(A). , substituted “requirements of section 300gg–26(a)” for “requirements of section 300gg–4(a)” and inserted at end “In applying the previous sentence with respect to requirements under paragraph (8) of , a benchmark benefit package or benchmark equivalent coverage described in such sentence shall be treated as in compliance with such requirements if the State plan under this subchapter or the benchmark benefit package or benefit equivalent coverage, as applicable, is in compliance with subpart C of part 440 of title 42, Code of Federal Regulations, or any successor regulation.”

Pub. L. 111–148, § 2001(a)(5)(E)section 1396a(a)(10)(A)(i) of this title2010—Subsec. (a)(1)(B). , inserted “subclause (VIII) of or under” after “eligible under”.

Pub. L. 111–148, § 2004(c)(2)section 1396a(a)(10)(A)(i)(IX) of this titleSubsec. (a)(2)(B)(viii). , inserted “, or the individual qualifies for medical assistance on the basis of ” before period at end.

Pub. L. 111–148, § 2001(c)(1)Subsec. (b)(1). , inserted “subject to paragraphs (5) and (6),” before “each of the following” in introductory provisions.

Pub. L. 111–148, § 2001(c)(2)(A)Subsec. (b)(2). , inserted “subject to paragraphs (5) and (6)” after “subsection (a)(1),” in introductory provisions.

Pub. L. 111–148, § 2001(c)(2)(B)Subsec. (b)(2)(A)(iv) to (vii). , added cls. (iv) and (v) and redesignated former cls. (iv) and (v) as (vi) and (vii), respectively.

Pub. L. 111–148, § 2001(c)(2)(C)Subsec. (b)(2)(C). , redesignated cls. (iii) and (iv) as (i) and (ii), respectively, and struck out former cls. (i) and (ii) which read as follows:

“(i) Coverage of prescription drugs.

“(ii) Mental health services.”

Pub. L. 111–148, § 2001(c)(3)Subsec. (b)(5), (6). , added pars. (5) and (6).

Pub. L. 111–148, § 2303(c)Subsec. (b)(7). , added par. (7).

Pub. L. 111–3, § 611(a)(1)(A)section 1396a(a)(1) of this title section 1396a(a)(10)(B) of this title2009—Subsec. (a)(1)(A). , in introductory provisions, substituted “Notwithstanding (relating to statewideness), (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 (E)” for “Notwithstanding any other provision of this subchapter” and “coverage that” for “enrollment in coverage that provides”.

Pub. L. 111–3, § 611(a)(1)(B)Subsec. (a)(1)(A)(i). , inserted “provides” before “benchmark coverage”.

Pub. L. 111–3, § 611(a)(1)(C)section 1396a(a)(10)(A) of this title section 1396d(r) of this titleSubsec. (a)(1)(A)(ii). , added cl. (ii) and struck out former cl. (ii) which read as follows: “for any child under 19 years of age who is covered under the State plan under , wrap-around benefits to the benchmark coverage or benchmark equivalent coverage consisting of early and periodic screening, diagnostic, and treatment services defined in .”

Pub. L. 111–3, § 611(a)(2)Subsec. (a)(1)(C). , substituted “additional” for “wrap-around” in heading and struck out “wrap-around or” before “additional” in text.

Pub. L. 111–3, § 611(a)(3)Subsec. (a)(1)(E). , added subpar. (E).

Pub. L. 111–3, § 611(b)Subsec. (a)(2)(B)(viii). , substituted “child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care or” for “aid or assistance is made available under part B of subchapter IV to children in foster care and individuals”.

Pub. L. 111–3, § 611(c)Subsec. (c). , added subsec. (c).

Statutory Notes and Related Subsidiaries

Effective Date of 2020 Amendment

section 209(a)(2) of Pub. L. 116–260Dec. 27, 2020section 209(a)(4) of Pub. L. 116–260 section 1396a of this titleAmendment by effective , and applicable to transportation furnished on or after such date, see , set out as a note under .

section 210(c) of Pub. L. 116–260Jan. 1, 2022section 210(e) of Pub. L. 116–260 section 1308 of this titleAmendment by applicable with respect to items and services furnished on or after , see , set out as a note under .

Effective Date of 2010 Amendment

section 2004(c)(2) of Pub. L. 111–148Jan. 1, 2014section 2004(d) of Pub. L. 111–148 section 1396a of this titleAmendment by effective , see , set out as an Effective and Termination Dates of 2010 Amendment note under .

section 2303(c) of Pub. L. 111–148Mar. 23, 2010section 2303(d) of Pub. L. 111–148 section 1396a of this titleAmendment by effective , and applicable to items and services furnished on or after such date, see , set out as an Effective and Termination Dates of 2010 Amendment note under .

Effective Date of 2009 Amendment

Pub. L. 111–3, title VI, § 611(d)Feb. 4, 2009123 Stat. 101

Pub. L. 109–171“The amendments made by subsections (a), (b), and (c) of this section [amending this section] shall take effect as if included in the amendment made by section 6044(a) of the Deficit Reduction Act of 2005 [].”

, , , provided that:

Effective Date

Pub. L. 109–171, title VI, § 6044(b)Feb. 8, 2006120 Stat. 92

March 31, 2006“The amendment made by subsection (a) [enacting this section] takes effect on .”

, , , provided that: