Frequently Asked Questions

CMS has previously provided guidance regarding the reporting of zero or negative AMP in Manufacturer Release #80 (January 5, 2010) in which we specify that if a calculated monthly AMP is zero or negative, we recommend that manufacturers report the most recent prior month's positive AMP. However, the actual calculated monthly AMP should be used to calculate the quarterly AMP. If the quarterly AMP is zero or negative, we recommend that manufacturers report the most recent positive AMP value. Please see Manufacturer Release #80: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Benefits/Prescription-Drugs/Downloads/Rx-Releases/MFR-Releases/mfr-rel-080.pdf. (PDF, 127.6 KB)

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FAQ ID:94851

The final rule does not require that a drug manufacturer sell its drugs to certain purchasers.

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FAQ ID:94856

Given the one year delay in the effective date of the definitions of states and United States, manufacturers should begin using sales data in their smoothing process beginning with sales that occur as of April 1, 2017.

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FAQ ID:94861

CMS regulations at 42 CFR 435.603(f)(2) provide that the parents would be included in the child's household in this situation. However, if the parents do not intend to continue to claim the child as a tax dependent for the following tax year, states may alternatively use the option provided at 435.603(h)(3) to consider the child's move to the live with another caretaker relative as a "reasonably predictable change in income" and apply the non-filer rules to the child at 435.603(f)(3). Under the non-filer rules, neither the parents nor the caretaker with whom the child is living would be included in the child's household for purposes of Medicaid and CHIP eligibility.

Note that to be claimed as a "qualifying child," children generally must live with their parents for at least half of the year (certain exceptions apply), but parents may also be able to continue to claim a child as a "qualifying relative." States are not expected to determine whether or not a parent is permitted to claim their child as a tax dependent or not, but states may wish to consult IRS Publication 501 to better understand the general requirements which must be met for a tax filer to claim another individual either as a "qualifying child" or "qualifying relative." IRS Publication 501 can be accessed at the following link: http://www.irs.gov/pub/irs-pdf/p501.pdf.

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FAQ ID:92571

For purposes of eligibility for coverage through the Marketplace, the Affordable Care Act defines Indians as individuals who are members of a federally recognized Indian Tribe. The definition of Indian currently in use for Medicaid beneficiaries follows a broader definition that includes descendants of Indians and all American Indians and Alaska Natives. As a result, American Indians and Alaska Natives who are not members of an Indian tribe would not be eligible for exemptions available through an Exchange, including from individual responsibility payments, qualification for special monthly enrollment periods and cost-sharing reductions.

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FAQ ID:92576

Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), Veterans' disability, Workers' Compensation, child support, federal tax credits, and cash assistance are common types of income that are not taxable. Please see Question 5 below for additional details on veterans' benefits.

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FAQ ID:92581

The IRS has provided guidance on how VA benefits should be considered when calculating income. As noted in IRS Publication 17, states should not count any veterans benefits paid under any law, regulation or administrative practice administered by the Department of Veterans Affairs in their income calculations. CMS agrees that VA benefits are not part of the Modified Adjusted Gross Income (MAGI) calculation.

Following are some examples of payments issued to veterans' or their families that are not taxable:

• Education, training and subsistence allowances
• Disability compensation and pensions payments for disabilities paid either to veterans or their families
• Grants for homes designed for wheelchair living
• Grants for motor vehicles for veterans who lost their sight or the use of their limbs
• Veterans' insurance proceeds and dividend paid either to veterans or their beneficiaries, including the proceeds of a veteran's endowment policy paid before death
• Interest on insurance dividends left on deposit with the VA
• Benefits under a dependent care assistance program
• The death gratuity paid to a survivor of a member of the Armed Forces who died after September 10, 2001
• Payments made under the compensated work therapy program
• Any bonus payment by a state or political subdivision because of service in a combat zone

Additional information on how the IRS views veteran's income can be found at http://www.irs.gov/pub/irs-pdf/p17.pdf.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92586

According to section 1902(e)(14)(D)(v) of the Act, implemented at 42 CFR 435.603(a)(3), a person enrolled in Medicaid on or before December 31, 2013, shall not be found ineligible solely because of the application of MAGI and new household composition rules before March 31, 2014, or the individual's next regular renewal date, whichever is later.

States have two options regarding implementation. They can apply both pre-MAGI rules and MAGI rules to anyone whose renewal date falls between January 1 and March 31, 2014 as described below. Alternately, states may request the waiver authority to delay renewals outlined in our May 17, 2013 guidance titled, "Facilitating Medicaid and CHIP Enrollment and Renewal in 2014" (available at http://medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO-13-003.pdf).

The steps described below will ensure that Medicaid enrollees who come up for renewal between January and March 2014 are addressed appropriately. For example, for an individual who comes up for renewal on February 1, 2014, states need to:

1. Conduct an eligibility redetermination by applying MAGI-based methods (at the converted income standard). If eligible, renew coverage for a 12-month period ending in February 2015.
2. If the individual is found to be ineligible under step 1, determine whether s/he remains eligible based on 2013 (current) methods and income standard. If so, a finding of eligibility until April 1, 2014 is necessary under the 2013 methods. Go to step 4.
3. If the individual is not eligible per either step 1 or 2, consider whether the individual might be eligible on other bases of eligibility, and pursue any possibilities. If no other pathways apply, provide the individual with notice of termination and appeal rights and transfer their account to the Exchange (or CHIP) for eligibility determination and enrollment in a QHP (or CHIP).
4. On April 1, 2014, for those who remain eligible per step 2 (using 2013 methods and income standards), consider whether the individual qualifies on other bases of eligibility. If the individual does, renew eligibility until April 1, 2015. If not, provide notice and appeal rights for termination effective April 1, 2014.

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FAQ ID:92596