Frequently Asked Questions

Yes. The CHIP enhanced FMAP will continue to be available for the expenditures for children shifted from CHIP to Medicaid, as long as their income is greater than the state's March 31, 1997 Medicaid income standard for children. In other words, if CHIP funding was available for this group of children when they were covered in a separate CHIP, it will continue to be available when the children are covered under Medicaid. The CHIP enhanced FMAP is available for uninsured children whose income exceeds that income standard, whether the children previously qualified for or were enrolled in a separate CHIP program or not.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)

FAQ ID:91871

Yes, consistent with Medicaid coverage rules. States must cover children ages 6-18 in the new mandatory Medicaid group and Medicaid is the secondary payer to other insurance. All children must be covered without regard to their insurance status but title XIX funds must be used to cover such children who have creditable health insurance.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)

FAQ ID:91876

Yes. As with children who move from a separate CHIP to Medicaid because of the change in Medicaid eligibility to 133 percent FPL, children moving from CHIP to Medicaid because of the application of the 5 percent disregard may also be funded through title XXI.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)

FAQ ID:91881

Yes. As stated in the Frequently Asked Questions pertaining to this provision posted on April 25, 2013, states may claim the enhanced match available under title XXI for children who lose Medicaid eligibility due to the elimination of income disregards as a result of the conversion to MAGI. These children now meet the definition of a targeted low-income child and will be enrolled in a separate CHIP in accordance with section 2101(f) of the ACA. If states choose the option to maintain Medicaid eligibility for such children title XIX funds and regular FMAP must be used to provide coverage.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)

FAQ ID:91886

Generally, no. Section 2105(c) (8) of the Social Security Act limits enhanced FMAP to the expenditures associated with children whose effective family income is at or below 300 percent FPL. Expenditures for children whose effective family income exceeds 300 percent of the FPL are matched at the regular Medicaid FMAP rate rather than the enhanced FMAP. However, the enhanced matching rate continues to be available for expenditures on populations whose income exceeds 300% FPL in states in which the income standard exceeds 300 percent as a result of MAGI conversion, as well as for states with approved income limits for CHIP above 300% of the FPL prior to the passage of the Children's Health Insurance Program Reauthorization Act (CHIPRA).

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• This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)

FAQ ID:91891

States are no longer allowed to cover parents in CHIP after Sept. 30, 2013 and therefore, are no longer eligible to receive the enhanced CHIP FMAP for expenditures for parents.

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FAQ ID:91896

As applicant information is entered into state systems, there will be some applicants that will be known to the system, such as people who previously applied to or enrolled in Medicaid, family members of current beneficiaries, and possibly beneficiaries of other human services programs. If, based on this information known to the system, the state finds information that indicates the individual is unlikely to be eligible for Medicaid under MAGI rules, then the state may treat such information as an inconsistency. Just as states are not enrolling applicants on the flat file who have an inconsistency in their income or residency information based on FFM verification without further evaluation, states may also not enroll applicants based on the flat-file data for whom there are discrepancies based on state system information. We will work with states that would like to pursue other options for dealing with information found in state systems when entering individuals from the flat file.

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FAQ ID:91911

This issue has been identified to be resolved but the state can proceed to enroll these accounts. The expanded flat file will contain several other fields giving enough information to effectuate enrollment while this issue is resolved. We will work with states that believe they have a problem proceeding to enroll these applicants.

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FAQ ID:91961

Beginning in 2014, the Affordable Care Act authorizes two types of increased federal medical assistance percentages (FMAPs) for state expenditures for low-income individuals in the new adult group (that is, the group described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (the Act)) - the newly eligible FMAP and the expansion state FMAP. Under the statute, these two increased federal matching rates are only available to states that adopt the new adult group.

The newly eligible FMAP is available for medical assistance expenditures on behalf of "newly eligible" individuals, who are defined (in section 1905(y)(2) of the Act) as individuals between the ages of 19 and 64 who are enrolled in the new adult group and who would not have been eligible for full benefits, benchmark coverage (described in subparagraph (A), (B), or (C) of section 1937(b)(1) of the Act), or benchmark-equivalent coverage (described in section 1937(b)(2) of the Act) as of December 1, 2009. An individual may also be "newly eligible" if he or she would have been eligible but could not have been enrolled for such benefits or coverage because the applicable Medicaid waiver or demonstration had limited or capped enrollment as of December 1, 2009.

The newly eligible FMAP (described in section 1905(y)(1) of the Act) is 100 percent in calendar years 2014-2016, 95 percent in calendar year 2017, 94 percent in calendar year 2018, 93 percent in calendar year 2019, and 90 percent in calendar years 2020 and beyond. The expansion state FMAP (described in section 1905(z)(2) of the Act) is an alternate increased FMAP available to match the expenditures for certain adults in states that previously expanded Medicaid and, as a result, may not qualify for the newly eligible FMAP. More details about the expansion state FMAP are included in Question 5. In our August 17, 2011 eligibility NPRM, we proposed that methods for assigning the appropriate FMAP would not require that states undertake the process of using their old eligibility rules to determine if someone would have been eligible under December 2009 rules. We have been consulting with states to test different methodologies for accuracy and simplicity.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 52.92 KB)

FAQ ID:94071

As described above, the newly eligible FMAP applies to adults in the new low-income adult eligibility group who would not have been eligible for full benefits, benchmark benefits, or benchmark-equivalent benefits under the state's rules as of December 1, 2009. At the time of approval of the section 1115 demonstrations in effect as of that date, neither CMS nor states explicitly designated the coverage offered under demonstrations as "benchmark" or "benchmark-equivalent" coverage, even though the coverage offered to demonstration beneficiaries may have met such standards. Therefore, CMS is requesting that states that used section 1115 demonstrations to expand coverage to low-income adults as of December 1, 2009 provide CMS with an analysis of the benefit package that was offered so that CMS can determine whether the benefits provided could have met a benchmark or benchmark equivalent standard, as in effect in December 2009. A separate analysis should be undertaken for each demonstration benefit package, if different demonstration populations received different benefits under the demonstration.

In conducting the benefit analysis, it will be important for states to utilize a consistent methodology and provide CMS with sufficient data to substantiate their analyses. States' benchmark-equivalence analyses must be certified by a qualified actuary and must include information on the data, assumptions, and methodology used to calculate actuarial values, in accordance with regulations implementing section 1937 of the Act, which are already in effect at 42 C.F.R. 440.330-340. CMS is working with all affected states (that is, states with demonstrations covering adults in effect on December 1, 2009) and will provide them with guidance about the form and manner in which to provide information about eligibility and benefits in effect as of December 1, 2009. CMS will use the benefit analysis that states provide to determine the appropriate FMAP. If any state has questions about this process, they should contact their State Operations and Technical Assistance (SOTA) team representative.

It is also important to note that if the benefit analysis described above indicates that the newly eligible FMAP is not available for a particular population, states may nevertheless be able to claim the expansion state FMAP for certain non-pregnant adults enrolled in the new adult group (as described in Question 5). CMS will work with each state that expanded coverage to adults prior to the enactment of the Affordable Care Act to address questions and to ensure that the correct FMAP is applied to expenditures for each population.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 52.92 KB)

FAQ ID:94076