Frequently Asked Questions

The final rule specifies that Medicaid and CHIP agencies will establish their verification policies and procedures in a verification plan. This plan is not a required element of the Medicaid State plan but States suggested, and CMS agrees, that it will be helpful to have the each State's eligibility verification process established in a written plan. The verification plans will serve many purposes, including ensuring PERM reviews are mindful of the State's verification policies and also for promoting coordination with the Exchange. States' verification plans will be public and available upon request, but we are not establishing a Federal approval process. State verification policies must of course always be consistent with applicable Federal at section 435.940 - 435.956 of the eligibility final rule.

The verification plans will include information about the data sources the State will use to verify applicant information, define reasonable compatibility standards, and determine when self attestation will be accepted. CMS will provide a verification plan template for States to use.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93176

Self-attestation is permitted for all factors of eligibility, except as required by law (i.e. citizenship and immigration status). States must accept self-attestation of pregnancy, unless information provided is not reasonably compatible with other information in the State's files.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93181

Under the Affordable Care Act, an Expansion State is one that had eligibility standards for parents and nonpregnant childless adults (under either the State plan or a demonstration project) to at least 100 percent of the FPL as of the date of enactment of the Affordable Care Act. Specifically, a State is an expansion State if, on March 23, 2010, the State offered health benefits coverage Statewide to parents and non-pregnant, childless adults whose income is at least 100 percent of the poverty line, that includes inpatient hospital services, is not dependent on access to employer coverage, employer contribution, or employment and is not limited to premium assistance, hospital-only benefits, a high deductible health plan, or alternative benefits under a demonstration program authorized under section 1938 of the act. A State that offers health benefits coverage to only parents or only non-pregnant childless adults described in preceding sentence will not be considered to be an expansion State; both groups must have been covered as described above.

The law established a special Federal medical assistance percentage (FMAP) for expansion States. Expansion States are able to claim a special FMAP for the non-pregnant childless adults who are not "newly eligible." These States can also claim the enhanced FMAP for individuals who are "newly eligible" in 2014. CMS is in the process of a 50-State review of State coverage as of March 23, 2010.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 42.98 KB)

FAQ ID:93191

Yes, in order to be eligible for enhanced FMAP for "newly eligible" individuals, an individual must be in the new adult group. The adult group is comprised of individuals that could include parents. Specifically, the group is comprised of individuals described in section 1902(a)(10)(A)(i)(VIII) of the Act who beginning January 1, 2014:

• Are under age 65
• Are not pregnant
• Not entitled to/enrolled for benefits under Medicare (Part A and B)
• Not described in the "(I) to (VII) Groups" (referring to individuals described in section 1902(a)(10)(I) - (VII) of the Act)
• Whose income is determined using MAGI and does not exceed 133% of the FPL

This list does not preclude parents from being in the adult group, but whether the State can claim enhanced FMAP depends on whether the parents are considered "newly eligible" ; that is, an individual who is not under 19 years of age (or higher age as the State may have elected) and who is not eligible under the State plan or under a waiver of the plan for full benefits or for benchmark coverage or benchmark equivalent coverage under State rules in effect as of December 2009, or is eligible but would not have been enrolled for such benefits or coverage through a waiver under the plan that has a capped or limited enrollment.

Thus, for any parents who are in the adult group because, for example, their income is greater than the income standard for parents in the State's parent/caretaker relative group in January 2014, the State will be able to claim enhanced FMAP if they would not have been eligible under the eligibility criteria in effect under the plan or waiver as of December 1, 2009.

Our proposed rules on this definition were issued in August 2011 (available at http://www.gpo.gov/fdsys/pkg/FR-2011-08-17/html/2011-20756.htm ); final rules are forthcoming. As discussed in the proposed rule, CMS intends to establish a methodology for States to claim enhanced FMAP without having to maintain and apply its December 1, 2009 eligibility rules to each individual.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 42.98 KB)

FAQ ID:93201

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.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:93411

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.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93716

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).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94661

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

FAQ ID:94526

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.

FAQ ID:95051

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.

FAQ ID:95071