Frequently Asked Questions

Preventive services include immunizations, screenings for common chronic and infectious diseases and cancers, clinical and behavioral interventions to manage chronic disease and reduce associated risks, and counseling to support healthy living and self-management of chronic conditions, such as those associated with obesity. A list of preventive health care services recommended as Grade A or B by the U.S. Preventive Services Task Force can be found at: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/.

Through Medicaid's children's benefit - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - children under age 21 enrolled in Medicaid are assured coverage for preventive and comprehensive health services. States cover adult preventive services within Medicaid through both mandatory and optional benefit categories. Some preventive services (such as those related to family planning) may be defined in a state's mandatory set of benefits while others may be included in the optional benefit category. As a result, Medicaid programs differ from state to state on the coverage of preventive services for adults.

Obesity-related services are those services that help prevent and manage unhealthy weight. Medicaid and CHIP programs can cover a range of services to prevent and reduce obesity including Body Mass Index (BMI) screening, education and counseling on nutrition and physical activity, prescription drugs that promote weight loss, and, as appropriate, bariatric surgery.

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Affordable Care Act Section 4004(i)(2) calls for "state public awareness campaigns to educate Medicaid enrollees regarding availability and coverage of preventive and obesity related services with the goal of reducing incidences of obesity." The statute tasks states with designing the public awareness campaign because states have a better understanding of what outreach efforts will best meet the needs of their state Medicaid and CHIP population. Activities that provide information to beneficiaries about the preventive and obesity-related services covered in the state's Medicaid and CHIP programs will satisfy the requirement. Federal funding would be available for such activities as administrative costs of the Medicaid and CHIP programs.

Some resources that states may want to consider as they move forward with their activities include:

• Healthy Weight, Healthy People, Healthy Communities page on the Health Resources and Services Administration's website
• Centers for Disease Control and Prevention's Nutrition, Physical Activity and Obesity 
• "F as in Fat: How Obesity Threatens America's Future 2012," issued by the Trust for America's Health and the Robert Wood Johnson Foundation

States can receive the 50 percent Medicaid administrative matching rate for public awareness campaign activities, and will receive their existing Federal Medical Assistance Percentage (FMAP) rate for preventive services.

The Affordable Care Act includes additional funding for states that cover Grade A and B recommended services of the US Preventive Services Task Force (USPSTF) and all Advisory Committee on Immunization Practices (ACIP) recommended adult vaccines and their administration without cost sharing. CMS has released separate guidance on that provision which can be found at https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SMD-13-002.pdf.

In addition, CMS can provide technical assistance to states with reporting and interventions that they have in place to improve performance on the prevention core measures.

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Yes, if a state has undertaken an initiative to provide information on Medicaid coverage of preventive services since the passage of the Affordable Care Act in March 2010 then they have met this requirement.

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Yes. However, the benefit package and cost-sharing structure must be in compliance with separate CHIP rules.

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Yes, states will need to submit a CHIP SPA for approval to provide coverage to children under this group in accordance with section 457.60. CMS will make available a simplified SPA template on which the state may report how these protected children will be identified and enrolled and information on benefits and cost-sharing.

Because of the flexibility provided states in establishing eligibility for separate CHIP programs, states could establish a group within an existing separate CHIP or as a standalone separate CHIP with eligibility criteria specific to the chosen option. For example, a state could establish a CHIP group with eligibility limited to children losing Medicaid at their 2014 redetermination using MAGI methodology. Coverage provided under this group would sunset when the last child eligible for 2101(f) protection came up for their first annual renewal in CHIP.

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Yes. States will need to conduct a renewal at the end of the 12-month separate CHIP coverage period in accordance with section 457.343 to determine if the child remains eligible for CHIP and, if not, to determine potential eligibility for other insurance affordability programs and transfer the child's account, as appropriate, to the Medicaid agency or the Exchange.

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As noted above, the protection afforded under section 2101(f) extends until the child comes up for his or her first regular renewal for coverage under the separate CHIP program, which would be 12 months from the child's transfer from Medicaid to the separate CHIP. When the last child eligible for protection under section 2101(f) comes up for renewal in the separate CHIP, the state may discontinue this part of its program.

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No. Systems programmed to determine eligibility based on 2013 rules would not properly determine eligibility based on MAGI methodologies and therefore could not be used to identify these children. Children protected by section 2101(f) are children who lose Medicaid eligibility after MAGI rules (including household composition and family income) are applied but would have remained eligible if the former disregards had also been applied.

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No. Section 2101(f) does not apply to children made ineligible for a separate CHIP as a result of the elimination of income disregards. Children losing coverage under a separate CHIP must be screened for eligibility for other insurance affordability programs and their cases electronically transferred per section 457.348.

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Yes. States may claim the enhanced match available under title XXI for children enrolled in a separate CHIP in accordance with section 2101(f).

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