Customized Benefit Packages. Some health plans may be authorized by the Agency to offer a customized benefit package for their Reform enrollees. Refer to Attachment I and Attachment II, Exhibit 5, for any information applicable to this Contract.
Customized Benefit Packages. (See Attachment I)
1. The capitated Health Plan shall submit a customized benefit package (CBP), which may vary the co-pays or the amount, duration and scope of the following services for non- pregnant adults: hospital outpatient not otherwise specified (NOS) and hospital outpatient physical, occupational, respiratory, and speech therapy services; and home health, dental, pharmacy, chiropractic, podiatry, vision, hearing and durable medical equipment as specified below.
a. Amount, duration and scope may vary for durable medical supplies (DME) with the exception of any prosthetic/orthotic supply priced over three-thousand dollars ($3,000) on the Medicaid fee schedule and except for motorized wheelchairs, which must be covered up to the Medicaid State Plan (State Plan) limit.
b. Dialysis services, contraceptives, and chemotherapy-related medical and pharmaceutical services must be covered up to the State Plan limit.
c. Hearing services for non-pregnant adults may vary in amount, duration and scope except for hearing aid services, which must be covered up to the State Plan limit.
d. The Health Plan shall provide all medically necessary services up to the State Plan limit in accordance with the Medicaid Handbook requirements for pregnant women, children/adolescents, and enrollees with a HIV/AIDS diagnoses as identified by the Agency.
2. Approved CBPs must comply with the benefit grid plan evaluation tool and instructions available from HSD. The Agency shall test the Health Plan’s CBP for actuarial equivalency and sufficiency of benefits, before approving the CBP. Actuarial equivalency is tested by using a benefit plan evaluation tool that:
a. Compares the value of the level of benefits in the proposed package to the value of the current Medicaid State Plan package for the average member of the covered population; and
b. Ensures that the overall level of benefits is appropriate.
3. Sufficiency is tested by comparing the proposed CBP to state-established standards. The standards are based on the covered population’s historical use of Medicaid State Plan services. These standards are used to ensure that the proposed CBP is adequate to cover the needs of the vast majority of the enrollees.
4. If, in its CBP, the Health Plan limits a service to a maximum annual dollar value, the Health Plan must calculate the dollar value of the service using the Medicaid fee schedule.
5. The CBPs may change on a Contract year basis and only if approved by the Agency in writing. Th...
Customized Benefit Packages. Capitated managed care plans will have the flexibility to provide customized benefit packages for demonstration enrollees as long as the benefit package meets certain minimum standards described in this STC, and actuarial benefit equivalency requirements and benefit sufficiency requirements described in STCs 28-32. PSNs operating under FFS must provide all benefits for all enrolled beneficiaries as are available under the state plan. The customized benefit packages must include all state plan services otherwise available under the state plan for pregnant women and children including all EPSDT services for children under age 21. The customized benefit packages must include all mandatory services specified in the state plan for all populations. The amount, duration and scope of optional services, may vary to reflect the needs of the plan’s target population and plans can offer additional services and benefits not available under the state plan. The plans contracted with the state shall not have service limits more restrictive than authorized in the state plan for children under the age of 21, pregnant women, and emergency services. The state may also capitate all state plan services for demonstration enrollees. Policies for determining medical necessity for children covered under the EPSDT benefit must be consistent with Federal statute at §1905(r) of the Social Security Act (the Act) in authorizing vision, dental, and hearing services, and other necessary health care, diagnostic services, treatment and other measures described in §1905(a) of the Act to correct or ameliorate defects and physical and mental illnesses and conditions discovered by screening services, whether or not such services are covered in the State plan.
