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Frequently Asked Questions

Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.

FAQ Library

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Can the State Operations and Technical Assistance Team (SOTA) calls replace the requirement for submitting an 1115 transition plan?

The SOTA calls cannot replace the submission of a transition plan, as the plan is a required deliverable under the State's Special Terms and Conditions. However, we expect to use the SOTA calls as a platform for transition planning discussions. We are also available for additional calls with States as needed. We can accept as the State's required early deliverable, a summary of the issues that the State needs to address in the transition plan, given the specific features of its waiver and plans for 2014. We will work with States in subsequent months to fully develop the transition plan to ensure it is in place in time for 2014.

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FAQ ID:93026

Could a State select a different Essential Health Benefits (EHB) benchmark reference plan for its Medicaid section 1937 alternative benefit plans than the EHB reference plan it selects for the individual and small group market?

Yes. A State is not required to select the same EHB benchmark reference plan for Medicaid section 1937 plans that it selects for the individual and small group market, and it could have more than one EHB benchmark reference plan for Medicaid (for example, if the State were to develop more than one benefit plan under section 1937).

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FAQ ID:93041

Could a State select its regular Medicaid benefit plan as its section 1937 alternate benefit plan for the new adult eligibility group?

Yes. A State could propose its traditional Medicaid benefit package as a section 1937 alternate benefit plan under the Secretary-approved option available under section 1937 of the Social Security Act. The State would have to ensure that the ten statutory categories of EHB are covered, either through that benefit plan or as a supplement to that plan.

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FAQ ID:93046

Do States need to track people enrolled in the adult group who become pregnant?

States are not required to track the pregnant status of women enrolled through the new adult group. Women who enroll in the adult group who later become pregnant will have the option of either staying enrolled in the adult group, or requesting that the State move them to a pregnancy-related eligibility group. This is most likely to occur if women need specific benefits that are not available under the adult group benchmark benefit package.

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FAQ ID:93136

How do the managed care rules at 42 CFR 438 apply to benchmark benefit plans?

The managed care regulations apply to all benefits delivered through a managed care delivery system, regardless of the authority under which the benefits are provided or enrollment is required. Thus, any State which uses a managed care organization to deliver benefits under the authority of section 1937 of the Act must comply with the managed care regulations at 42 CFR 438.

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FAQ ID:93051

How does CMS define the term "Expansion State"? Which States are "expansion States"?

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.

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FAQ ID:93191

How is CMS envisioning the "shared eligibility service" that will support interactions between insurance affordability programs and help ensure a seamless enrollment experience for consumers?

The process for making a MAGI-based eligibility determination is largely the same for all insurance affordability programs. The Affordable Care Act requires a single, streamlined application, accompanied by a similar set of business rules and verification processes, and an adjudication work flow that is largely identical between Exchanges, Medicaid and CHIP programs.

It is expected that State agencies that receive Federal funds from CMS to establish State-based Exchanges and provide for Medicaid and CHIP expansions coordinate efforts to produce a shared eligibility service or system that relies on a shared IT infrastructure and as such, cost allocate this service.

A shared eligibility service is not the same as one system. We define an eligibility service as a set of IT functions that produce an eligibility determination based upon MAGI. (For more information, see IT Guidance 2.0, http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Data-and-Systems/Downloads/exchangemedicaiditguidance.pdf.) The service incorporates an application, a set of verifications (for citizenship, income, residency, etc.) and business rules that together determine how much financial assistance a consumer should receive to acquire affordable health insurance.

While policies codified in final regulations allow legal authority for eligibility determinations to remain with state Medicaid agencies (for Medicaid) and Exchanges (for premium tax credits and cost-sharing reductions), the underlying business rules and processes are nearly identical, and should, to the maximum extent practical, rely upon a shared IT service(s) and infrastructure.

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FAQ ID:93071

How will Essential Health Benefits (EHB) be defined for Medicaid benchmark or benchmark-equivalent plans?

Since 2006, State Medicaid programs have had the option to provide certain groups of Medicaid enrollees with an alternative benefit package known as "benchmark" or "benchmark-equivalent" coverage, based on one of three commercial insurance products or a fourth, "Secretary-approved" coverage option. Beginning on January 1, 2014, all Medicaid benchmark and benchmark-equivalent plans must include at least the ten statutory categories of Essential Health Benefits. Under the Affordable Care Act, the medical assistance provided to the expansion population of adults who become newly eligible for Medicaid as of January 1, 2014, must be provided consistent with section 1937 benchmark authority.

For Medicaid alternative benefit plans, three of the benchmark plans described in section 1937 (the State's largest non-Medicaid HMO, the State's employee health plan, and the FEHBP BCBS plan) may be designated by the Secretary as EHB benchmark reference plans, as described in the EHB Bulletin (link below). A State Medicaid Agency could select any of these section 1937 benchmark plans as its EHB benchmark reference plan for Medicaid. There would be no default EHB benchmark reference plan for purposes of Medicaid; each State Medicaid Agency would be required to identify an EHB benchmark reference plan for purposes of Medicaid as part of its 2014-related Medicaid State Plan changes.

If the EHB benchmark reference plan selected for Medicaid were to lack coverage within one or more of the ten statutorily-required categories of benefits, the section 1937 alternative benefit plan would need to be supplemented to ensure that it provides coverage in each of the ten statutory benefit categories. This would be in addition to any other requirements for Section 1937 plan, including Mental Health Parity and Addition Equity Act compliance.

For more information about the Essential Health Benefits, please see CCIIO's bulletin from December 2011 (available at http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf ) and the CMCS informational bulletin from February 2012 (available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-02-17-12.pdf (PDF, 71.68 KB).

FAQ ID:93036

If a State's demonstration is expiring in 2012, can the State request an extension?

Yes. CMS will continue to consider section 1115 demonstration extension requests. However, the State's proposal must include a plan to address changes in its demonstration that would need to take place to ensure readiness for 2014. Please also note that extension requests are subject to the recently issued transparency final rule (http://www.gpo.gov/fdsys/pkg/FR- 2012-02-27/html/2012-4354.htm )and corresponding State Health Officials letter (http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SHO-12-001.pdf (PDF, 136.08 KB) (PDF 0 bytes)), which outlines the new public notice comment and process requirements.

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FAQ ID:93031

If a woman indicates on the application she is pregnant, do States need to enroll her as a pregnant woman if she is otherwise eligible for the adult group? Would there be a need to track pregnancy if the benefits for both groups are the same?

If a woman indicates on the application that she is pregnant, she should be enrolled in Medicaid coverage as a pregnant woman. The Affordable Care Act specifies that pregnant women are not eligible for the new adult group. As mentioned above, if a woman enrolled in the adult group later becomes pregnant, she will have the option to stay enrolled in the adult group or request that the State move her to a pregnancy-related eligibility group.

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FAQ ID:93141

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