EliciaJ. Herz
Specialist in Health Care Financing
TheMedicaid program, which served 69 million people in FY2011, finances thedelivery of a wide variety of preventive, primary and acute care servicesas well as long-term services and supports for certain low-incomepopulations. Benefits are available to beneficiaries through two avenues.First, the traditional Medicaid program covers a wide variety of mandatoryservices (e.g., inpatient hospital services, lab/x-ray services, physiciancare, nursing facility care for persons aged 21 and over) and otherservices at state option (e.g., prescribed drugs, physiciandirected clinicservices, physical therapy, prosthetic devices) to the majority of Medicaid beneficiariesacross the United States. Within broad federal guidelines, states define theamount, duration, and scope of these benefits. Thus, even mandatoryservices are not identical from stateto- state.
The Deficit Reduction Act of 2005 (DRA; P.L. 109-171) created an alternativebenefit structure for Medicaid. Under this authority, states may enrollcertain Medicaid subpopulations into benchmark benefit plans that includefour choices: (1) the standard Blue Cross/Blue Shield preferred providerplan under the Federal Employees Health Benefits Program, (2) a plan offered tostate employees, (3) the largest commercial health maintenance organization inthe state, and (4) other coverage appropriate for the targeted population,subject to approval by the Secretary of Health and Human Services (HHS).
Since the enactment of the Patient Protection and Affordable Care Act in 2010(ACA; P.L. 111- 148, as amended), benchmark benefits have taken on a newimportance in the Medicaid program. As per the ACA, a new mandatory groupof non-elderly, non-pregnant adults with income up to 133% of the federalpoverty level will be eligible for Medicaid beginning in 2014, or sooner at stateoption. (For more information about a recent Supreme Court ruling regardingthis group, see CRS Report RL33202, Medicaid: A Primer.) Theseindividuals will be required to enroll in benchmark plans rather thantraditional Medicaid (with some exceptions for subgroups with specialmedical needs). However, to date, only a handful of states have experienceadministering these plans, nearly all of which have been tailored tospecific subpopulations.
The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT)estimated that coverage expansion provisions in the ACA would increaseenrollment by about 7 million in FY2014, rising to 11 million by FY2022 inboth the Medicaid and the State Children’s Health Insurance Programs(Congressional Budget Office, Estimates for the Insurance Coverage Provisionsof the Affordable Care Act Updated for the Recent Supreme Court Decision, July 2012).Many of these new enrollees will get benchmark benefits. To assist Congress inevaluating the current scope of benefits available under Medicaid, thisreport outlines the major rules that govern and define both traditionalMedicaid and benchmark benefits. It also compares the similarities anddifferences between these two benefit package designs.
Date of Report: August 3, 2012
Number of Pages: 16
Order Number: R42478
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