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Eligibility

The Affordable Care Act expands coverage for the poorest Americans by creating an opportunity for states to provide Medicaid eligibility, effective January 1, 2014, for individuals under 65 years of age with incomes up to 133 percent of the federal poverty level (FPL). For the first time, states can provide Medicaid coverage for low-income adults without children and be guaranteed coverage through Medicaid in every state without need for a waiver. Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment will be much simpler and will be coordinated with the newly created Affordable Insurance Exchanges.

See current information on eligibility.

Areas of interest under this provision:

Section-by-Section Summary – Exchange/Medicaid/CHIP Eligibility, Notices and Appeals, and Alternative Benefit Plans Proposed Rule:To assist you in your review and understanding of our latest proposed rule addressing a range of policy issues including eligibility appeals and notices, alternative benefit plans, cost sharing, and continued streamlining of Medicaid and CHIP eligibility rules, we have developed the attached "section-by-section summary" of the rule. 

Medicaid and CHIP Eligibility and Enrollment: Creating a streamlined system of affordable coverage for Medicaid, CHIP, and the Affordable Insurance Exchanges (Effective 2014). On March 16, 2012, CMS released its eligibility and enrollment final rule to assist States in implementing the Affordable Care Act Medicaid coverage expansion. 

On January 14, 2013, CMS put on display a proposed rule that builds on its Medicaid and CHIP eligibility and enrollment final rule released in March 2012.  The proposed rule would lay out a structure and options for coordinating Medicaid, CHIP, and Exchange eligibility notices and appeals; provide additional benefits and cost-sharing flexibility for state Medicaid programs; and codify several provisions included in the Affordable Care Act and Children's Health Insurance Program Reauthorization Act (CHIPRA).

Early Option to Provide Medicaid to Adults Prior to 2014: Providing federal funding to states that expand Medicaid eligibility, between April 1, 2010 and January 1, 2014, to individuals with incomes below 133 percent of the FPL.

Maintenance of Effort: Maintaining existing coverage for adults until the implementation of coverage changes effective in January 2014 and for children through September 2019.

Former Foster Care Children: Establishing eligibility for children who have aged-out of the foster care system and had previously received Medicaid while in foster care, until they turn 26. Foster care children will remain eligible for the full scope of Medicaid benefits (Effective January 1, 2014).

Family Planning: Establishing a new Medicaid eligibility group and the option for states to begin providing medical assistance for family planning services and supplies.

Presumptive Eligibility in Hospitals: Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations.

Real Time Determinations: Outlines the CMS regulatory language and guidance provided to States about the vision of streamlined, accurate and timely eligibility determinations and what steps States could take to work towards that goal.