Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
How will Essential Health Benefits (EHB) be defined for Medicaid benchmark or benchmark-equivalent plans?
Since 2006, State Medicaid programs have had the option to provide certain groups of Medicaid enrollees with an alternative benefit package known as "benchmark" or "benchmark-equivalent" coverage, based on one of three commercial insurance products or a fourth, "Secretary-approved" coverage option. Beginning on January 1, 2014, all Medicaid benchmark and benchmark-equivalent plans must include at least the ten statutory categories of Essential Health Benefits. Under the Affordable Care Act, the medical assistance provided to the expansion population of adults who become newly eligible for Medicaid as of January 1, 2014, must be provided consistent with section 1937 benchmark authority.
For Medicaid alternative benefit plans, three of the benchmark plans described in section 1937 (the State's largest non-Medicaid HMO, the State's employee health plan, and the FEHBP BCBS plan) may be designated by the Secretary as EHB benchmark reference plans, as described in the EHB Bulletin (link below). A State Medicaid Agency could select any of these section 1937 benchmark plans as its EHB benchmark reference plan for Medicaid. There would be no default EHB benchmark reference plan for purposes of Medicaid; each State Medicaid Agency would be required to identify an EHB benchmark reference plan for purposes of Medicaid as part of its 2014-related Medicaid State Plan changes.
If the EHB benchmark reference plan selected for Medicaid were to lack coverage within one or more of the ten statutorily-required categories of benefits, the section 1937 alternative benefit plan would need to be supplemented to ensure that it provides coverage in each of the ten statutory benefit categories. This would be in addition to any other requirements for Section 1937 plan, including Mental Health Parity and Addition Equity Act compliance.
For more information about the Essential Health Benefits, please see CCIIO's bulletin from December 2011 (available at http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf ) and the CMCS informational bulletin from February 2012 (available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-02-17-12.pdf (PDF, 71.68 KB).
FAQ ID:93036
SHARE URLCould a State select a different Essential Health Benefits (EHB) benchmark reference plan for its Medicaid section 1937 alternative benefit plans than the EHB reference plan it selects for the individual and small group market?
Yes. A State is not required to select the same EHB benchmark reference plan for Medicaid section 1937 plans that it selects for the individual and small group market, and it could have more than one EHB benchmark reference plan for Medicaid (for example, if the State were to develop more than one benefit plan under section 1937).
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ÂFAQ ID:93041
SHARE URLCould a State select its regular Medicaid benefit plan as its section 1937 alternate benefit plan for the new adult eligibility group?
Yes. A State could propose its traditional Medicaid benefit package as a section 1937 alternate benefit plan under the Secretary-approved option available under section 1937 of the Social Security Act. The State would have to ensure that the ten statutory categories of EHB are covered, either through that benefit plan or as a supplement to that plan.
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ÂFAQ ID:93046
SHARE URLHow do the managed care rules at 42 CFR 438 apply to benchmark benefit plans?
The managed care regulations apply to all benefits delivered through a managed care delivery system, regardless of the authority under which the benefits are provided or enrollment is required. Thus, any State which uses a managed care organization to deliver benefits under the authority of section 1937 of the Act must comply with the managed care regulations at 42 CFR 438.
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ÂFAQ ID:93051
SHARE URLWill 1915(c) waivers continue in the future?
Yes. 1915 (c) waivers are optional programs that most States currently operate and can continue to operate. States interested in making changes to their 1915(c) waivers should contact their CMS Regional Office with specific questions.
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ÂFAQ ID:93056
SHARE URLCan states rely on the information contained in the enhanced flat files?
We believe these files have information that states can rely on. As with any transmission of data or logic process, discrepancies may arise. However, we have done quality reviews and continue to act on reports of issues as quickly as possible by investigating them and introducing systems fixes as needed. We are continuing our testing and quality assurance efforts as well. We expect that states will be doing the same on accounts transferred from states to the FFM. We will continue to rely on our daily desk officer calls and our SOTA process to follow up with states on any questions that may arise.
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FAQ ID:91906
SHARE URLWhat action may the state take if the state believes there is another basis for excluding an individual from flat file-based enrollment based on state analysis or external information?
If the state would like to exclude individuals from enrollment based on the flat file, please reach out to CMCS to discuss the state's options. Our goal in offering this flat file option is to provide an additional avenue for enrollment and we will work with states on how they might best maximize the use of these files.
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FAQ ID:91921
SHARE URLWhat if a state later determines that a person enrolled based on information in the flat file is not eligible for Medicaid or CHIP?
In a letter dated November 29, 2013, (see http://www.medicaid.gov/Federal-PolicyGuidance/downloads/SHO-13-008.pdf (PDF, 117.76 KB)) CMS offered states the opportunity to apply for a waiver under section 1902(e)(14)(A) of the Social Security Act to allow them to make temporary enrollment decisions based on the information included in the flat file. So, as long as states follow the procedures outlined in the guidance and other applicable rules with respect to eligibility and claiming, federal funding is available for this temporary enrollment. Individual's circumstances might change and other factors might arise that could change the outcome of the eligibility determination once the state evaluates eligibility based on the full account transfer. Federal funding is not at risk for states that follow appropriate procedures to enroll beneficiaries based on the FFM's determination or assessment of eligibility.
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FAQ ID:91926
SHARE URLWe understand that if we use the expanded flat file for enrollment, applicants are eligible to receive Medicaid for 90 days for assessment states and that we will run them through a MAGI-based determination in the future. If we enroll someone based on the flat file, and then become aware of additional information regarding the individual's eligibility before we receive the full account transfer, do we need to act on that information?
Since the waiver is a temporary grant of authority, if changes in circumstance are reported then states have the flexibility to choose to act on reported changes immediately or wait until the full determination occurs. If a state has the capability to review and process the changes reported they can do so, and if a state does not wish to act upon reported changes during this temporary waiver period that is also permissible. States should discuss with CMS how to document the state's policy regarding changes in circumstance in the waiver request.
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FAQ ID:91931
SHARE URLIf an application contains a household which is a mixed case with MAGI and non-MAGI individuals, how should the state process enrollment in this situation?
Because the Federally Facilitated Marketplace (FFM) is providing eligibility determinations/assessments for Medicaid under the MAGI standard, the state can process enrollment for MAGI individuals under the waiver authority. Since the FFM is providing non-MAGI applicant referrals on the expanded flat file, the state would act upon the non-MAGI referrals in the same manner as it would through the account transfer service.
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FAQ ID:91936
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