DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
CMCS Informational Bulletin 
DATE:  September 16, 2014  
FROM:          Cindy Mann 
              Director 
    Center for Medicaid & CHIP Services (CMCS) 
SUBJECT:     Process for Amending Alternative Benefit Plans 
This informational bulletin provides information on the timeframes and requirements for 
amending Medicaid Alternative Benefit Plans (ABP) when states are in full or partial alignment 
between the ABP benefit package and the states approved Medicaid state plan package for other 
categorically or medically needy eligible. This bulletin also includes information about 
expectations for public and tribal notification, as well as the system to use for state plan 
amendment (SPA) submissions.   
Background 
Under section 1937 of the Social Security Act, states have the flexibility to design an ABP 
entirely based on commercial market benefits or the states approved Medicaid state plan, or a 
combination of both. When a state designs its ABP benefit package to be the same benefits or 
richer benefits than the states approved Medicaid state plan, the state has achieved alignment 
between the ABP benefit package and the states approved underlying Medicaid state plan.  To 
date, most states have chosen the path of aligning their ABP benefit package fully or in part with 
the states approved Medicaid state plan.   
Section 1302 of the Affordable Care Act, as codified at 45 CFR 156.110 of the Essential Health 
Benefit regulation published by the Center for Consumer Information and Insurance Oversight 
(CCIIO), requires that beginning in 2014, qualified health plans offered on Exchanges and non-
grandfathered individual and small group coverage offered by insurers must include the 10 broad 
categories of coverage called Essential Health Benefits (EHBs).  The regulations preamble 
language further specified that the benchmark plan selection in 2012 would be applicable for at 
least the 2014 and 2015 benefit years, thus freezing EHBs at their 2012 level until December 31, 
2015.   
The suspension of updating EHB benefits for two years was intended to bring stability to the 
marketplace while the full breadth and depth of the transition to the requirements under 
Affordable Care Act was realized.  CMS carried this suspension over to the benefits from the 
commercial market base benchmark plan, which are used to define the floor of coverage for 
EHBs into ABPs.  States are therefore not required to update their base benchmark plans in terms  CMCS Informational Bulletin Page 2 
 
of essential health benefits until at least December 31, 2015.  It should be noted that the standard 
Medicaid state plan is not subject to the freezing of benefits because it is not considered a base 
benchmark plan. 
ABP Amendment Requirements 
ABPs must be kept in full or partial alignment with the states approved underlying state plan on 
an ongoing basis, not just at the point of initial approval for those states that have chosen to align 
with their Medicaid state plan.  ABP submissions that are aligned with the states approved 
Medicaid state plan are inclusive of all benefits in the state plan, in one submission.  In order to 
maintain alignment, states are required to submit an amendment to update the benefits in the 
ABP and states will be required to include in the amendments changes that impact the approved 
ABP.  For example, state plan amendments that add, delete or change coverage based on 
limitations of amount, duration or scope or authorization requirements will need to be included 
in the new ABP submission.  Amendments that affect provider qualifications, for example, will 
not need to be addressed by amending the ABP, as the ABP does not require an articulation of 
individual providers.    
Appreciating that this is the first year of ABP submissions, we are allowing states extra time to 
ensure that their SPAs are properly updated to maintain alignment.  States should submit updates 
to the ABP submission that includes all changes for the first three calendar quarters no later than 
December 31, 2014.  Thereafter, states will be required to update the ABP submissions on a 
quarterly basis to keep the ABP in alignment with the states approved underlying Medicaid state 
plan.  We recognize that state plan amendments for the states approved state plan may have 
different effective dates even if submitted in the same quarter.  Therefore, we will need to reflect 
those effective dates for each benefit within the ABP, which will result in the ABP having an 
overall effective date for the submission and potentially different effective dates by benefit 
category within the ABP.   
With regard to the timing of amendments to the ABP related to essential health benefits, CMS 
will be issuing additional information regarding updating of the benefits in the underlying 
commercial market benefit package used to define essential health benefits, as these benefits are 
frozen until 12/31/15.   
Public Notice and Tribal Notification 
States are required to issue public notice prior to submission of a new ABP or changes to an 
existing ABP.  Publication of such notice must provide for a reasonable opportunity to comment 
and have included in the notice a description of the method for assuring compliance with            
 440.345 related to full access to Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) services.  This requirement affects the timing of the ABP submission, as states have 
until the last day of the calendar quarter to submit SPAs to preserve the effective date for the first 
day of the quarter.    CMCS Informational Bulletin Page 3 
 
States are also required to notify Tribes prior to the submission of a new ABP or changes to an 
existing ABP.  Tribal notification must be conducted according to the tribal notification process 
that has been specified in the state plan. We believe that the tribal notice that state will need to 
conduct for regular state plan benefits will suffice for this process in ABPs.  
The public notice process and the tribal notification process can be quite lengthy in some state, 
(up to 60 days) and state should plan accordingly. States that do not publish the public notice or 
provide tribal notification prior to submitting a new ABP or an amendment to an existing ABP 
will be required to revise the effective date of the submission, which could jeopardize the 
ongoing alignment between the ABP and underlying Medicaid state plan.  
New SPA Submission Process 
 
States should continue to use the MMDL to submit SPAs until the MACPro system is 
implemented. MACPro is an online system CMS is developing to facilitate submission of 
applications to amend existing Medicaid and CHIP state plans and waivers.  It will be phased-in 
over time, with Phase I including ABP SPAs.  Additional information will be issued on the status 
of MACPro and its use for ABP submissions.  As part of this activity, we will also continue to 
work with states to implement changes to SPA templates to make the process of maintaining 
alignment as smooth as possible.