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Basic Health Plan Methodology Final for 2016

The Centers for Medicare & Medicaid Services (CMS) has published final methodology for 2016 to determine federal payments to states that offer a Basic Health Program (BHP) as an affordable alternative to health insurance marketplace coverage.

The new methodology, which is largely the same as for 2015 except for several updated values, begins Jan. 1, 2016.  As required by the Affordable Care Act, federal payments to states will continue to equal 95 percent of the premium tax credit and cost-sharing assistance that would have been provided to BHP consumers if they enrolled in a marketplace plan instead. Payments will be calculated quarterly, based on the last quarter enrollment, and reconciled as states submit enrollment data each quarter.

The BHP allows states to provide affordable health care coverage to low-income individuals who are otherwise eligible to purchase coverage through the marketplaces, but may be unable to afford a marketplace plan. Individuals must have household incomes between 133 percent and 200 percent of the federal poverty level and must not be eligible for Medicaid or affordable, employer-sponsored coverage. In March 2014, CMS released a final rule to set state and federal BHP standards.

Contact Beth Feldpush, DrPH, senior vice president of policy and advocacy, at or 202.585.0111 with questions.


About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.

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