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.
Frequently Asked Questions
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).
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.
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.
Will 1915(c) waivers continue in the future?
Yes. 1915 (c) waivers are optional programs that most States currently operate and can continue to operate. States interested in making changes to their 1915(c) waivers should contact their CMS Regional Office with specific questions.
Will children enrolled in CHIP as of March 23, 2010 who become eligible for Medicaid as a result of the conversion to Modified Adjusted Gross Income (MAGI) and the expansion of Medicaid coverage for children up to 133 percent of the FPL, be eligible for the CHIP enhanced FMAP?
Yes. CHIP enhanced FMAP will continue to be available for children whose income is greater than the Medicaid applicable income level (defined in section 457.301 and based on the 1997 Medicaid income standard for children), regardless of whether those children are enrolled in Medicaid or CHIP. This includes children who previously qualified for CHIP in a separate program and children whose family incomes are up to 133 percent of the Federal poverty level, and therefore will be newly eligible for Medicaid in 2014.
Will States need to add a separate CHIP coverage group in order to meet the requirements of section 2101(f) of the Affordable Care Act, the provision that requires States to ensure continuity of coverage for children who lose Medicaid eligibility as a result of the conversion to MAGI?
Yes. Section 2101(f) of the Affordable Care Act provides that States maintain coverage under a separate CHIP program for children who lose Medicaid eligibility due to the elimination of income disregards as a result of the conversion to MAGI. We anticipate that this provision will directly impact a relatively small number of children, and are committed to helping States implement this provision in a manner that is not unduly burdensome or costly and still protects the continuity of coverage for these children as required by statute.
For States with only Medicaid Expansion CHIPs, one approach is to create a separate CHIP that is substantively identical to the existing program, thereby creating the greatest continuity of coverage for the child, the least confusion for the family, and the most efficient operation for the state. For States with existing separate CHIPs, a State plan amendment assuring that these children will be covered through that program for as long as they qualify should be sufficient.
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.
- This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB) (PDF 46.1 KB)
Will the agreements between Medicaid/CHIP agencies and Exchanges regarding coordination be subject to public disclosure and/or public comments?
The agreement between Medicaid/CHIP agencies and Exchanges regarding coordination must be available to the Secretary upon request and will be subject to applicable disclosure laws, such as the Freedom of Information Act.
Will the Federally-Facilitated Exchange (FFE) only do assessments of Medicaid and CHIP eligibility or if a State desires will the FFE also make eligibility determinations for Medicaid and CHIP?
States can work with the Federally-Facilitated Exchange (FFE) regarding Medicaid and CHIP eligibility determinations in one of two ways. The State may either establish an agreement whereby the FFE assesses applicants for Medicaid/CHIP eligibility based on MAGI and then transfers the applicants' electronic accounts to the State Medicaid or CHIP agency to complete the eligibility determination. Or the State may elect to accept MAGI-based eligibility determinations completed by the FFE as final determinations. Regardless of the approach, the process should be as seamless as possible for the applicant with most eligibility determinations completed in near real-time as specified in our eligibility final rule at 435.912.
In the case where the Exchange is conducting an eligibility assessment and then transferring the applicant's information to the State Medicaid or CHIP agency to complete the eligibility determination, what standards will the Exchange use to make the assessment for Medicaid and CHIP eligibility?
The Exchange will utilize the State's Medicaid and CHIP eligibility rules for conducting both eligibility determinations and eligibility assessments. This will include application of the State's MAGI income standards and related eligibility rules for the MAGI population. The Exchange will also rely on a robust verification protocol that is consistent with Medicaid and CHIP regulations but which might not be the same protocol the State is otherwise using.
If a State accepts assessments of eligibility from the Federally-Facilitated Exchange (FFE) and chooses to make the final eligibility determinations itself, once an individual has been assessed as Medicaid/CHIP eligible, their electronic account would be transferred to the State Medicaid or CHIP agency, which will complete the eligibility determination. This process will include any additional verification required by the State that is consistent with the Federal verification regulations.