Alternative Benefit Plan
A. The Commonwealth provides alternative benefits to the adult group (defined in § 1902(a)(10)(A)(i)(VIII) of the Social Security Act) under the coverage option under § 1937 of the Social Security Act (42 USC § 301 et seq.) approved by the Secretary of Health and Human Services. Enrollment is mandatory for individuals in the adult group, and the alternative benefit package shall be available statewide.
B. In developing the benefit package for the alternative benefit plan, the Commonwealth reviewed:
1. Benefits in its approved State Plan as a "benchmark benefit package";
2. The largest plan by enrollment of the three largest small-group insurance products in the small-group market as the "base benchmark plan"; and
3. Essential health benefits.
C. Alternative benefit plan services.
1. The alternative benefit plan includes all Medicaid State Plan services, including essential health benefits.
2. The essential health benefits included in the alternative benefit plan are ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management. Pediatric services, including oral and vision care, are essential health benefits that are not covered for adults.
D. The Commonwealth will use both managed care and fee-for-service delivery systems for the alternative benefit plan.
1. The managed care delivery system is the same as the CMS-approved § 1915(b) managed care waivers. The fee-for-service delivery system is the traditional, state-managed system.
2. For each benefit provided under an alternative benefit plan that is not provided through managed care, the Commonwealth will use the payment methodology in its approved state plan (12 VAC 30-70, 12 VAC 30-80, and 12 VAC 30-90).
E. Individuals who have cost-effective group health plans described in § 1906 of the Social Security Act or qualified employer-sponsored plans described in § 1906A of the Social Security Act may request to receive coverage through the Health Insurance Premium Payment program.
F. Any cost sharing described in Attachment 4.18-A of the State Plan (12VAC30-20-150) applies to the alternative benefit plan.