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% 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:

Medicaid and Children’s Health Insurance Programs: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP  

This Medicaid and CHIP Eligibility, Notices and Fair Hearing and Appeals Processes Final Rule (effective January 20, 2017) addresses policies to support modernization of notices and appeals processes and the coordination of eligibility notices and appeals across insurance affordability programs.  The final rule also completes and complements policies reflected in the March 16, 2012 eligibility and enrollment final rule to simplify Medicaid and CHIP eligibility and enrollment rules, including coverage for former foster care youth, optional eligibility groups, and verification of citizenship and immigration status.

Proposed Rule:  Medicaid and Children’s Health Insurance Programs: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid 

This proposed rule completes and complements the fair hearing and appeals policies included in the Medicaid and CHIP Eligibility, Notices and Fair Hearing and Appeals Processes Final 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. 

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).

CMS also issued an Informational Bulletin, entitled “Section 1115 Demonstration Opportunity to Allow Medicaid Coverage to Former Foster Care Youth Who Have Moved to a Different State,” that informs states how they can pursue a section 1115 demonstration project to provide coverage to former foster care youth who aged out of foster care under the responsibility of another state (and were enrolled in Medicaid while in foster care), and are now applying for Medicaid in the state in which they live.

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.

Medicaid/CHIP Eligibility Verification Plans

Medicaid and CHIP agencies now rely primarily on information available through data sources (e.g., the Social Security Administration, the Departments of Homeland Security and Labor) rather than paper documentation from families for purposes of verifying eligibility for Medicaid and CHIP. For more information on each state’s eligibility verification plan.

MAGI Conversion Plans and Results

CMS provided states with a template for completing their “MAGI Conversion Plans” that are designed to reflect the MAGI-based eligibility standards that are used to determine Medicaid and CHIP eligibility.   The MAGI-conversion process involved a translation of pre-2014 net income eligibility standards into MAGI-based eligibility standards. Moving to MAGI replaced income disregards with simpler, more universal income eligibility rules that are generally aligned with the rules that are used to determine eligibility for the premium tax credits in the Marketplace. To complete the transformation to MAGI, states needed to “convert” their net-income based eligibility standards to MAGI-based standards. For more information on each state’s MAGI conversion plan and MAGI conversion results.

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% of the FPL.