Medicaid Model Data Lab
Medicaid and CHIP Form Repository
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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