Medicaid Alternative Benefit Plan PDF Forms
PDF Forms:
- ABP1: Alternative Benefit Plan Populations
- ABP2a: Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A)(i)(VIII) of the Act
- ABP2b: Voluntary Enrollment Assurances for Eligibility Groups other than the Adult Group under Section 1902(a)(10)(A)(i)(VIII) of the Act
- ABP2c: Enrollment Assurances - Mandatory Participants
- ABP3:
Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package
(Use only if ABP has an effective date earlier than 1/1/2020 or if only changing the Section 1937 Coverage Option of an ABP implemented before 1/1/2020) - ABP3.1:
Selection of Benchmark Benefit or Benchmark-Equivalent Benefit Package
(Use only for ABP's effective on or after 1/1/2020) - ABP4: Alternative Benefit Plan Cost-Sharing
- ABP5: Benefits Description
- ABP6: Benchmark-Equivalent Benefit Package
- ABP7: Benefits Assurances
- ABP8: Service Delivery Systems
- ABP9: Employer Sponsored Insurance and Payment of Premiums
- ABP10: General Assurances
- ABP11: Payment Methodology