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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.

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Can the Marketplace determine Medicaid eligibility for non-MAGI groups?

If the Marketplace is a government entity, States will have the option to enable their State-based Exchange to make Medicaid eligibility determinations for non-MAGI eligibility groups. Depending on the arrangements made in each State, such an Exchange can make all Medicaid eligibility determinations, only eligibility determinations based on MAGI, or assessments of eligibility based on MAGI. The FFE will not be making Medicaid eligibility determinations for non-MAGI groups; the FFE will either do final determinations or assessments for the MAGI eligibility groups.

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FAQ ID:93091

Is CMS planning to draft a standard agreement for State Medicaid and CHIP agencies to use with the State-based Exchange?

Yes. CMS is working with States to develop a model agreement, and it is one of the tools that the Coverage Expansion Learning Collaborative will be considering.

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FAQ ID:93096

In situations where an Exchange makes Medicaid eligibility assessments rather than full determinations, will the determination be able to happen in real-time?

The goal is to have a seamless experience for consumers, with eligibility determinations made as quickly as possible regardless of which approach to eligibility determinations is in effect in a particular State. CMS will be establishing, in collaboration with States and with an opportunity for public input, data reporting measures that will allow States, CMS and the public to have information about the enrollment process including the timing of eligibility determinations under different design approaches.

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FAQ ID:93111

Can a State require Medicaid applicants who are applying to a State Medicaid agency to apply using the single streamlined application and therefore not get screened for a non-MAGI eligibility category?

The single streamlined application will contain questions that are designed to identify individuals who may be eligible for Medicaid on a basis other than MAGI. Today, many States use a simplified application that includes questions about disability status or the need for longterm care. The single streamlined application will have similar questions to help identify individuals who may need a Medicaid determination on a basis other than MAGI. Once identified, the individuals would be asked to complete a supplemental application, or a separate application for non-MAGI groups. The application will be developed with State and public input; we will be interested in suggestions on how best to screen for non-MAGI eligibility.

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FAQ ID:93116

Is there a potential conflict with the Medicaid requirement to process an application within 45 days and the Exchange rule that allows applicants 90 days to respond to requests to resolve information that is not reasonably compatible?

The requirements are different, but they are not in conflict. The 45-day limit for Medicaid is the outer boundary limit by which a State must determine Medicaid eligibility for all individuals who apply on a basis other than disability, and as discussed above, we expect much quicker determinations in most cases. The Medicaid program provides a reasonable opportunity period for individuals whose citizenship or immigration status cannot be verified. Medicaid provides benefits for individuals during their reasonable opportunity period, who are otherwise eligible for Medicaid. The Exchange rule provides for a 90-day reasonable opportunity period for all factors of eligibility. The Exchange determines eligibility without delay and then provides a 90-day reasonable opportunity period for the applicant to provide any additional required information.

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FAQ ID:93121

What does it mean for an individual to withdraw their Medicaid application in order to receive a determination of eligibility for Advance Premium Tax Credits (APTCs)?

In a State where the Exchange makes Medicaid and CHIP eligibility assessments, but not eligibility determinations, there are certain requirements that the Exchange must follow (found at 42 CFR 155.302(b)) in order to ensure a smooth transition between programs. When an eligibility assessment reveals that an applicant is potentially eligible for Medicaid or CHIP, the Exchange must transmit the individual's electronic account to the Medicaid or CHIP agency for completion of the eligibility determination.

However, when an eligibility assessment reveals that an applicant does not appear to be Medicaid or CHIP-eligible, the Exchange does not have the authority to deny Medicaid/CHIP eligibility (because that is not the arrangement in that State). The Exchange has the responsibility to notify applicants that they do not appear to be Medicaid/CHIP-eligible and provide them with the opportunity to either seek a formal Medicaid eligibility determination (which would delay the eligibility determination for an APTC), or to withdraw their application for Medicaid/CHIP and receive a determination for an APTC and a cost-sharing reduction (section 155.305(b)(4)). We will address in further guidance how the withdrawal will be addressed in the case of an appeal of an APTC decision.

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FAQ ID:93126

Which eligibility groups were consolidated under the March 2012 eligibility final rule?

The Medicaid eligibility final rule at 435.110, 435.116 and 435.118 set forth the mechanism for consolidating certain federal eligibility categories into four main groupings: adults, children, pregnant women and parents/caretaker relatives. The table provided below lays out the consolidation of mandatory and optional eligibility groups (a version of this table was also included as part of the preamble to the proposed rule).

Realignment of Medicaid Eligibility Groups

Before After Affordable Care Act Final Rule
Mandatory Medicaid Eligibility Groups (Pre-Affordable Care Act)

Parents/Caretaker Relatives

(section 435.110)

Pregnant Women

(section 435.116)

Children <19

(section 435.118)

Low-Income Families - 1902(a)(10)(A)(i)(I) and 1931 Former AFDC - 435.110 x x x

Qualified Pregnant Women & Children<19 -1902="" a="" 10="" a="" i="" iii="" -="" 435="" 116="" p="">

x x
Poverty-Level Related Pregnant Women & Infants - 1902(a)(10)(A)(i)(IV) - No rule x x
Poverty-Level Related Children Ages 1-5 - 1902(a)(10)(A)(i)(VI) - No rule x
Poverty-Level Related Children Ages 6-18 - 1902(a)(10)(A)(i)(VII) - No rule x

Optional Medicaid Eligibility Groups (Pre-Affordable Care Act)

Parents/Caretaker Relatives


Pregnant Women


Children <19


Families & Children Financially Eligible for AFDC - 1902(a)(10)(A)(ii)(I) - 435.210 x
Families & children Who Would be Eligible for AFDC if Not Institutionalized - 1902(a)(10)(A)(ii)(IV) - 435.211 x x
Poverty-Level Related Pregnant Women & Infants - 1902(a)(10)(A)(ii)(IX) - No rule x x

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FAQ ID:93131

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

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

In 2014, will the eligibility groups for people with breast and cervical cancer and disabled workers continue to exist?

Yes, the breast and cervical cancer group and the eligibility group for working disabled individuals will remain optional eligibility groups which States may elect. The Affordable Care Act did not alter the financial or non-financial requirements or methodologies used to determine eligibility for these groups, both of which are exempt from the application of Modified Adjusted Gross Income (MAGI) methodology for determining income.

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FAQ ID:93151

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