Frequently Asked Questions

Yes, the breast and cervical cancer group and the eligibility group for working disabled individuals will remain optional eligibility groups which States may elect. The Affordable Care Act did not alter the financial or non-financial requirements or methodologies used to determine eligibility for these groups, both of which are exempt from the application of Modified Adjusted Gross Income (MAGI) methodology for determining income.

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Coverage under section 1931 of the Act was not repealed with the ACA and will remain in effect in 2014. As noted in the table above, eligibility for parents and caretaker relatives under section 1931 is implemented at section 435.110 of the regulations; eligibility for pregnant women under section 1931 is implemented at section 435.116 and eligibility for children at section 435.118. TMA under section 1925 of the Act will sunset on December 31, 2012, unless extended by Congress. If Congress elects to extend section 1925 of the Act beyond December 31, 2013, States will need to provide TMA to eligible individuals as set forth in their approved State plans. Note that the 4-month extension for individuals losing eligibility under section 1931 of the Act due to increased earnings or hours of work (see sections 1902(e)(1)(A) and 1931(c)(2) of the Act), and the 4-month extension of eligibility for individuals losing eligibility due to increased spousal support (see section 1931(c)(1) of the Act) do not have a sunset date and would therefore still apply in 2014 unless repealed by Congress. The extension of eligibility for individuals losing coverage under section 1931 due to increased child support will no longer be relevant in 2014, as child support is not counted as income under MAGI-based methodologies.

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Yes. People with disabilities or who need long term care services and supports may qualify under the new adult group in 2014 if they meet the MAGI-based eligibility standards for that group. In addition, under the final eligibility and enrollment rule, eligibility for the new adult group based on MAGI does not preclude eligibility for coverage under an optional group that might be otherwise excepted from MAGI methods. Individuals with MAGI-based income up to 133% of the federal poverty level who meet the criteria for the adult group but who need long term services and supports, can choose to enroll in an optional group that better meets their needs, and they can move from the adult group to the optional eligibility group at any time, if eligible. Individuals found eligible for the new adult group based on MAGI, but who appear on the application to be potentially eligible for Medicaid on a basis other than MAGI, will be offered a more thorough eligibility determination so that they can have this option.

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States may continue to provide coverage to medically needy individuals in 2014, and indeed are required to offer such coverage with respect to children until the maintenance of effort requirement provision in section 1902(gg) of the Act expires. States have the option to discontinue coverage under medically needy groups for adults (e.g., disabled individuals with income above the standard for categorical eligibility) in 2014, subject to section 1902(gg). In States that continue to cover existing medically needy adult groups, adults who meet the categorical eligibility and resource requirements will have the ability to spend down to the medically needy income standard and receive the benefits covered for medically needy individuals in the State, or to enroll in the adult group (provided they meet the eligibility requirements for that group, including being under 65 and not eligible for Medicare).

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Verification services that are conducted as part of the eligibility determination process or to validate a client's attestation, after an eligibility record has been entered into the system, will be eligible for 75 percent FFP.

Those verifications performed post eligibility and normally initiated as part of a sampling approach, including audits, PERM or MEQC activities would be considered program integrity activity and eligible for the 50 percent FFP.

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Use our dentist locator to find a dentist that accepts Medicaid.

No. Under section 438.356 of the Final Rule, states can contract with one or more EQROs to conduct EQR activities and other related tasks (such as production of the EQR report).

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The ASD-related services for EPSDT eligible individuals (under age 21) must be provided under the Medicaid state plan and not under the 1915(c) waiver. When the state submits the home and community-based services waiver for renewal or amendment, the state should include a restriction under the "limits" section for that specific service indicating that EPSDT-aged individuals are excluded as the services are fully covered in the state plan. ASD-related services for individuals over age 21 may continue to be provided under the 1915(c) waiver.

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Alignment with the state's system development life cycle happens during the Project Initiation phase, specifically during Activity 1: Consult with CMS. The state should incorporate CMS milestone reviews into the state's project schedule. The flexibility is in scheduling, not whether milestone reviews are performed. Decisions made between the state and CMS are documented in the Project Partnership Understanding document and can be updated as needed throughout the life cycle.

At a minimum, quarterly. Depending on the risk of project activity, the state and CMS may agree that more frequent reporting is appropriate. Any frequency greater than quarterly should be captured in the Project Partnership Understanding document.