Medicaid Premium Assistance Programs: What Information is Available About Benefit and Cost-Sharing Wrap-Around Coverage?


Thank you very much for your willingness to answer a short survey on your premium assistance program. We are mindful of how valuable your time is and have tried to keep this survey brief.

The purpose of this study is to examine the provision of wraparound benefits in state Medicaid premium assistance programs. Wraparound benefits are additional benefits and/or lower cost-sharing provided by Medicaid but not typically covered in a beneficiary’s private insurance plan.

We are approaching you because in a 2010 study conducted by the Government Accountability Office (GAO) entitled Medicaid and CHIP: Enrollment, Benefits, Expenditures, and Other Characteristics of State Premium Assistance Programs, STATE reported MEDICAID OR PROGRAM NAME expenditure data on the costs of wraparound benefits for FY 2009. Your state reported XXXX.

We are interested in both STATE’s provision of benefits covered by Medicaid that are not covered by the beneficiaries’ private insurance plans as well as expenditures to reimburse additional cost-sharing charges (such as deductibles, copayments and coninsurance) when private insurance charges are higher than those permitted by Medicaid.

  1. For the most recent fiscal year available, please share enrollment and overall program expenditures for your premium assistance program.
  2. For the same fiscal year, please share expenditures on premium subsidies, “wrapped benefits” i.e. benefits not covered by the beneficiary’s private insurance, and cost-sharing charges paid by the state on the beneficiaries’ behalf. We would appreciate if you could be as specific as possible.
  3. Please briefly describe for us how the wraparound works in practice –
    1. How do beneficiaries learn about and access benefits that are covered by Medicaid but not by their private insurance plan?
    2. How are providers reimbursed for additional benefits covered by the Medicaid program and on what fee schedule?
    3. How is cost-sharing tracked and reimbursed? Do beneficiaries pay out-of-pocket at the point of service, and if so, are copayments limited to the Medicaid amounts?
    4. Are there different cost-sharing reimbursement rules for providers that are participating Medicaid providers and those that are not?
  1. Please share with us any program materials that you provide to beneficiaries to help them understand and access their wraparound benefits and cost-sharing protections. Are there other resources available to beneficiaries (such as call centers) if they have questions?
  2. Please share with us any additional information and/or observations you have about issues associated with providing wraparound benefits and cost sharing protections.
Issue Brief

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