Frequently Asked Questions

The Exchange will utilize the State's Medicaid and CHIP eligibility rules for conducting both eligibility determinations and eligibility assessments. This will include application of the State's MAGI income standards and related eligibility rules for the MAGI population. The Exchange will also rely on a robust verification protocol that is consistent with Medicaid and CHIP regulations but which might not be the same protocol the State is otherwise using.

If a State accepts assessments of eligibility from the Federally-Facilitated Exchange (FFE) and chooses to make the final eligibility determinations itself, once an individual has been assessed as Medicaid/CHIP eligible, their electronic account would be transferred to the State Medicaid or CHIP agency, which will complete the eligibility determination. This process will include any additional verification required by the State that is consistent with the Federal verification regulations.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93086

If the Marketplace is a government entity, States will have the option to enable their State-based Exchange to make Medicaid eligibility determinations for non-MAGI eligibility groups. Depending on the arrangements made in each State, such an Exchange can make all Medicaid eligibility determinations, only eligibility determinations based on MAGI, or assessments of eligibility based on MAGI. The FFE will not be making Medicaid eligibility determinations for non-MAGI groups; the FFE will either do final determinations or assessments for the MAGI eligibility groups.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93091

Yes. CMS is working with States to develop a model agreement, and it is one of the tools that the Coverage Expansion Learning Collaborative will be considering.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93096

The goal is to have a seamless experience for consumers, with eligibility determinations made as quickly as possible regardless of which approach to eligibility determinations is in effect in a particular State. CMS will be establishing, in collaboration with States and with an opportunity for public input, data reporting measures that will allow States, CMS and the public to have information about the enrollment process including the timing of eligibility determinations under different design approaches.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93111

The single streamlined application will contain questions that are designed to identify individuals who may be eligible for Medicaid on a basis other than MAGI. Today, many States use a simplified application that includes questions about disability status or the need for longterm care. The single streamlined application will have similar questions to help identify individuals who may need a Medicaid determination on a basis other than MAGI. Once identified, the individuals would be asked to complete a supplemental application, or a separate application for non-MAGI groups. The application will be developed with State and public input; we will be interested in suggestions on how best to screen for non-MAGI eligibility.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93116

The requirements are different, but they are not in conflict. The 45-day limit for Medicaid is the outer boundary limit by which a State must determine Medicaid eligibility for all individuals who apply on a basis other than disability, and as discussed above, we expect much quicker determinations in most cases. The Medicaid program provides a reasonable opportunity period for individuals whose citizenship or immigration status cannot be verified. Medicaid provides benefits for individuals during their reasonable opportunity period, who are otherwise eligible for Medicaid. The Exchange rule provides for a 90-day reasonable opportunity period for all factors of eligibility. The Exchange determines eligibility without delay and then provides a 90-day reasonable opportunity period for the applicant to provide any additional required information.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93121

In a State where the Exchange makes Medicaid and CHIP eligibility assessments, but not eligibility determinations, there are certain requirements that the Exchange must follow (found at 42 CFR 155.302(b)) in order to ensure a smooth transition between programs. When an eligibility assessment reveals that an applicant is potentially eligible for Medicaid or CHIP, the Exchange must transmit the individual's electronic account to the Medicaid or CHIP agency for completion of the eligibility determination.

However, when an eligibility assessment reveals that an applicant does not appear to be Medicaid or CHIP-eligible, the Exchange does not have the authority to deny Medicaid/CHIP eligibility (because that is not the arrangement in that State). The Exchange has the responsibility to notify applicants that they do not appear to be Medicaid/CHIP-eligible and provide them with the opportunity to either seek a formal Medicaid eligibility determination (which would delay the eligibility determination for an APTC), or to withdraw their application for Medicaid/CHIP and receive a determination for an APTC and a cost-sharing reduction (section 155.305(b)(4)). We will address in further guidance how the withdrawal will be addressed in the case of an appeal of an APTC decision.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93126

The Medicaid eligibility final rule at 435.110, 435.116 and 435.118 set forth the mechanism for consolidating certain federal eligibility categories into four main groupings: adults, children, pregnant women and parents/caretaker relatives. The table provided below lays out the consolidation of mandatory and optional eligibility groups (a version of this table was also included as part of the preamble to the proposed rule).

Realignment of Medicaid Eligibility Groups

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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93131

States are not required to track the pregnant status of women enrolled through the new adult group. Women who enroll in the adult group who later become pregnant will have the option of either staying enrolled in the adult group, or requesting that the State move them to a pregnancy-related eligibility group. This is most likely to occur if women need specific benefits that are not available under the adult group benchmark benefit package.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93136

If a woman indicates on the application that she is pregnant, she should be enrolled in Medicaid coverage as a pregnant woman. The Affordable Care Act specifies that pregnant women are not eligible for the new adult group. As mentioned above, if a woman enrolled in the adult group later becomes pregnant, she will have the option to stay enrolled in the adult group or request that the State move her to a pregnancy-related eligibility group.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93141