Wraparound Benefits in Premium Assistance Demonstrations

Arkansas, Iowa, and New Hampshire expanded Medicaid coverage to adults with incomes up to 138 percent of the federal poverty level using section 1115 authority to support beneficiaries’ purchase of coverage from qualified health plans. These premium assistance demonstrations must ensure that beneficiaries have access to certain Medicaid benefits not typically covered by qualified health plans, such as the Early and Periodic Screening, Diagnostic, and Treatment services for 19- and 20-year-olds and family planning services from any willing provider. In this brief, we review the requirements for these “wraparound” benefits, assess the status of their implementation, and discuss their implications for Medicaid beneficiaries’ access to care.

All three states implemented wraparound benefits using procedures that are like the ones they use to administer wraparound benefits in their other premium assistance programs, notably their Health Insurance Premium Payment programs. All three states chose to give beneficiaries a Medicaid card to present to providers, who then bill the state for the wraparound benefits. States’ demonstration monitoring reports to the Centers for Medicare & Medicaid Services do not provide sufficiently detailed data to assess wraparound benefit utilization and associated administrative costs, although the upcoming national evaluation of section 1115 demonstrations will include an analysis of wraparound benefit claims.