§ 1396u–7.
(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
The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under section 8903(1) of title 5.
(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—
(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
For purposes of subsection (a)(1), subject to paragraphs (5) and (6)
1
So in original. Probably should be followed by a comma.
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:
(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—
(5)
Minimum standards
Effective January 1, 2014, any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) must provide at least essential health benefits as described in section 18022(b) of this title, and beginning January 1, 2022, coverage of routine patient costs for items and services furnished in connection with participation in a qualifying clinical trial (as defined in section 1396d(gg) of this title).
(6)
Mental health services parity
(A)
In general
In 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 section 300gg–26(a) of this title 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 section 300gg–26(a) of this title, 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.
(7)
Coverage of family planning services and supplies
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 such coverage includes for any individual described in section 1396d(a)(4)(C) of this title, medical assistance for family planning services and supplies in accordance with such section.
(8)
COVID–19 vaccines, testing, and treatment
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, during the period beginning on
March 11, 2021, 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
section 1320b–5(g)(1)(B) of this title, 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
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], title XIX, § 1937, as added [Pub. L. 109–171, title VI, § 6044(a)], Feb. 8, 2006, [120 Stat. 88]; amended [Pub. L. 111–3, title VI, § 611(a)]–(c), Feb. 4, 2009, [123 Stat. 100], 101; [Pub. L. 111–148, title II], §§ 2001(a)(5)(E), (c), 2004(c)(2), 2303(c), Mar. 23, 2010, [124 Stat. 275], 276, 283, 296; [Pub. L. 116–260, div. BB, title II, § 203(a)(4)(B)], div. CC, title II, §§ 209(a)(2), 210(c), Dec. 27, 2020, [134 Stat. 2917], 2986, 2991; [Pub. L. 117–2, title IX, § 9811(a)(5)], Mar. 11, 2021, [135 Stat. 211].)