Frequently Asked Questions

Section 1311(i) of the Affordable Care Act directs an Exchange - whether a State-Based Exchange or a Federally-Facilitated Exchange - to establish a program under which it awards grants to Navigators. Section 1311(i) and 45 C.F.R. section 155.210 articulate the required duties of a Navigator. In addition, section 155.210(c)(2) directs that the Exchange select two different types of entities as Navigators, one of which must be a community and consumer-focused non-profit group. This program is further described in the "General Guidance on Federally-facilitated Exchanges."

The number of Navigators per state served by a Federally-Facilitated Exchange will be contingent upon the total amount of funding available as well as the number of applications that we receive in each state in response to the forthcoming Navigator Grant Funding Opportunity Announcement that we plan to issue early next year to support the Federally-Facilitated Exchanges.

Additionally, a state or Exchange cannot require Navigators to hold a producer license (i.e., a license as an agent or broker) for the purpose of carrying out any of the duties required of Navigators in section 1311(i)(3) of the Affordable Care Act and 45 C.F.R. section 155.210(e). Because the law directs Navigators to carry out all required duties, linking a producer license to any one of those specific duties would have the effect of requiring all Navigator entities, their employees, and their sub-grantees to hold a producer license. As described above, this would prevent the application of the standard set forth in 45 C.F.R. section 155.210(c)(2) that at least two different types of entities must serve as Navigators. As such, and as provided by section 1321(d) of the Affordable Care Act, any state laws which would require all Navigators to hold a producer license would be preempted by 45 C.F.R. section 155.210(c)(2).

In Federally-Facilitated Exchanges and State Partnership Exchanges, individuals selected to receive Navigator grants or working for entities selected to receive Navigator grants must successfully participate in an HHS-developed and administered training program, which will include a certification examination pursuant to 45 C.F.R. section 155.210(b). In addition, under state law, states may impose Navigator-specific licensing or certification requirements upon individuals and entities seeking to operate as Navigators, so long as such licenses or certifications are not preempted by the requirement to award to different types of entities identified in 45 C.F.R. section 155.210(c)(2), such as producer licenses.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

In-person assistance programs are an additional mechanism through which Exchanges may meet the consumer assistance responsibilities of the Exchange under 45 C.F.R. section 155.205(d) and (e). As described in the Federally-facilitated Exchange Guidance, states operating under a State Partnership Exchange will build and operate an in-person assistance program, for which grant funding is available under section 1311 of the Affordable Care Act, distinct from the Navigator program for that Exchange. State-Based Exchanges may do so as well. The purpose of providing multiple tools for in-person assistance is to ensure that all consumers can receive help when accessing health insurance coverage through an Exchange.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

Section 1413 of the Affordable Care Act directs HHS to develop a single, streamlined application that will be used to apply for coverage through qualified health plans, Medicaid and CHIP. In addition, it can be used by persons seeking the advance payment of premium tax credits and cost sharing reductions available for qualified health plans through the Exchange. In consultation with states and other stakeholders, and with the benefit of extensive consumer testing, HHS has been developing an on-line and paper version of the single, streamlined application. We are releasing information on a rolling basis both to seek public comment and to support states in their eligibility system builds.

In July 2012, HHS published a notice in the Federal Register outlining the initial data elements that will be included in the streamlined application for public comment. HHS received over 60 comments from states and other stakeholders that have helped inform our ongoing development work. These comments, coupled with ongoing consumer testing, have helped us refine and improve the application.

Consumer testing and extensive consultation with states and consumer groups continues. HHS expects to provide the final version of the online and paper application in early 2013 and will also work with states that seek Secretarial approval for their own application.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

The 90/10 funding is not contingent on a state's decision to proceed with its Medicaid expansion. As the preamble to the final regulation makes clear, the enhanced funding was not solely for eligibility determination systems that support the Medicaid expansion. (76 Fed Reg 21950-21975 (April 19, 2011) and 42 CFR Part 433.
CMS was clear in the final rule that enhanced funding could be available for eligibility determination systems that determine eligibility for traditional eligibility groups. However, such systems must meet all requirements, standards and conditions included in the final rule, including the Standards and Conditions for Medicaid IT that ensure modernized and efficient eligibility systems that produce accurate and timely eligibility determinations and that can interface seamlessly with the Exchange operating in that state. In all states, including those that do not proceed with the expansion, state eligibility systems must be able to electronically pass accounts between the Exchange (whether state-based or federally-facilitated) in order to facilitate seamless coordination. In addition, the systems must be able to support a single streamlined application for coverage among insurance affordability programs, support Modified Adjusted Gross Income (MAGI)-based eligibility determinations; and must support new renewal processes and connections for data-driven, electronic verifications as described in the Medicaid eligibility final rule issued March 23, 2012 (available at http://www.gpo.gov/fdsys/pkg/FR-2012-03- 23/pdf/2012-6560.pdf ).
States are not required to "build in" programming for the new adult group. However, a state that conforms to the Standards and Conditions for Medicaid IT (particularly modular design and separation of business rules from core programming) will be able to quickly and efficiently support enrollment for the expansion population. In addition, enhanced funding is available for states that wish to explicitly "build in" placeholder programming for the new adult group now to provide for future flexibility.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

CMS has developed the Medicaid Eligibility and Enrollment Toolkit (MEET) to provide guidance for states that are conducting E&E systems projects. The MEET is available at https://www.medicaid.gov/medicaid/data-and-systems/meet/index.html.

Also, various artifacts developed by states are posted in a shared environment for reuse by others. These artifacts can be used to help jump-start projects. More information on reuse, including access to the reuse repository, is available at https://www.medicaid.gov/medicaid/data-and-systems/reuse/index.html.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

There is no deadline by which states need to decide on the Medicaid expansion. We understand that there are many considerations involved in this decision, and CMS stands ready to work with states on their individual timetables. Regardless of the expansion, every state that uses the Federally Facilitated Exchange will need to support coordination between the Medicaid and CHIP programs and the FFE and otherwise comply with the new MAGI rules as well as the application, renewal and verification procedures described in the Medicaid eligibility final rule issued March 23, 2012 (available at http://www.gpo.gov/fdsys/pkg/FR-2012-03-23/pdf/2012- 6560.pdf). We will be working with each state to ensure that the appropriate business rules are accommodated and tested, and the necessary electronic account handoffs are in place, before the FFE is operational and the new Medicaid rules are in effect. We are continuing to provide more guidance and information on these issues as part of the FFE manual and MOU process as well as through our SOTA calls. We are also establishing a state- to- FFE change process to help manage changes in policies that a state may make over time; a state that decides later to proceed with expansion will be accommodated within that process.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

As previously stated in a letter from the Secretary to the nation's governors, the Supreme Court held that a state may not lose federal funding for its existing Medicaid program if the state chooses not to participate in the expansion of Medicaid eligibility for low-income adults. The Court's decision did not affect other provisions of the law. State Medicaid and CHIP programs will need to coordinate with the Federally-facilitated Exchange, regardless of a state's decision to proceed with expansion. States will need to be part of the seamless system for people to apply for all coverage programs; and will need to coordinate eligibility with the new insurance affordability programs. These provisions have relevance regardless of whether a state chooses to participate in the expansion for low-income adults.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

The FFE's role is the same whether or not a state implements the Medicaid expansion for low-income adults. The FFE will still make MAGI-based determinations or assessments of eligibility for Medicaid and CHIP and will assess eligibility for premium tax credits and cost sharing. The FFE will apply the state's eligibility levels for Medicaid/CHIP when it makes the Medicaid determination or assessment. In addition, as established in the Exchange and Medicaid/CHIP eligibility final rules, the FFE will electronically transfer accounts for individuals who are either determined or assessed as eligible for Medicaid and CHIP (it is a state option whether to have the FFE determine or assess eligibility) for further evaluation/action.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

The federal hub will provide data verification services to any state-based exchange and to the Medicaid and CHIP program without regard to whether a state has adopted the low-income adult expansion. Consistent with the regulations issued on March 23, 2012, state Medicaid and CHIP programs must rely on the HUB for certain information; this provision applies without regard to whether a state has adopted the Medicaid expansion for low-income adults.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

The Federal data services hub will provide the following services on Day 1. CMS is also pursuing data sources for additional verifications through the Federal data services hub and will keep states updated as they are confirmed:

• Social Security Number (SSN) verification via the Social Security Administration (SSA)
• Citizenship verification via SSA or the Department of Homeland Security (DHS) when relevant
• Incarceration verification via SSA
• Title II benefit income information via SSA (monthly and annual amounts)
• Quarters of coverage information via SSA
• MAGI income information from the Internal Revenue Service (IRS)
• Max APTC from IRS
• Immigration status verification via DHS, as well as a translation to indicators for lawful presence, qualified non-citizen, and five year bar status.
• Public minimum essential coverage (MEC) verification from Federal agencies