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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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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

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.

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FAQ ID:93056

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.

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FAQ ID:93061

Will section 1115 demonstrations continue beyond December 31, 2013?

The section 1115 waiver authority continues and whether a particular waiver continues will vary by State. CMS has been working with States individually to determine the appropriate waivers and expenditure authorities that will be extended beyond December 31, 2013. For example, States that have utilized demonstrations to expand eligibility to the childless adult population will no longer need the expenditure authority because this population will become a mandatory State plan population under the Affordable Care Act's Medicaid eligibility expansion. On the other hand, States that have utilized demonstrations to undertake delivery system reforms may still require waivers and/or expenditure authorities to execute those reforms beyond December 31, 2013.

CMS will work with States to develop and submit the transition plans that are required by the Special Terms and Conditions of each demonstration. These transition plans will serve as a vehicle for discussion of the various options that States will have in 2014 and beyond, including for populations with incomes above 133 percent of the Federal poverty level (FPL). CMS will engage with States during State Operations and Technical Assistance (SOTA) calls to work through State-specific transition issues.

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FAQ ID:93016

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.

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FAQ ID:93066

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.

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FAQ ID:93076

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.

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FAQ ID:93081

Are all of the Federal data hub services separate ("atomic"), such as SSN validation, and citizenship, or will they be wrapped into a single, "composite" service?

Some services will be composite, and others atomic. For instance, it will be possible to invoke individual SSA services in a single composite service, although not all services in the composite will always need to be invoked. If the Exchange is seeking Title II income information for a member of a household who is not the applicant, then the citizenship and incarceration services would not be invoked. In contract, public MEC verification services will be separate, atomic services.

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FAQ ID:93276

Can states use the data verified through the Federal data services hub for other programs, aside from Medicaid/CHIP eligibility?

Each federal agency has the authority to define use of its data. Therefore CMS defers to IRS, DHS and SSA who are partnering with us to provide data via the Federal data services hub. Please refer to the CMS Services Catalog to review the Business Service Description (BSD) for the verification of income service to identify the Federal tax information data elements and definitions that will be made available to states through the Federal data services hub.

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FAQ ID:93306

CMS has advised states that the 90/10 matching funds for modernization of Medicaid eligibility and enrollment (E&E) systems is not related to a state's decision about whether to proceed with the Medicaid expansion for the new adult group. Is 90/10 funding contingent on a state complying with other aspects of the Affordable Care Act related to eligibility? Must a state that uses 90/10 funding build into its design and development support for the new "adult group," even if it does not plan now to proceed with the expansion?

The 90/10 funding is not contingent on a state's decision to proceed with its Medicaid expansion. As the preamble to the final regulation makes clear, the enhanced funding was not solely for eligibility determination systems that support the Medicaid expansion. (76 Fed Reg 21950-21975 (April 19, 2011) and 42 CFR Part 433.
CMS was clear in the final rule that enhanced funding could be available for eligibility determination systems that determine eligibility for traditional eligibility groups. However, such systems must meet all requirements, standards and conditions included in the final rule, including the Standards and Conditions for Medicaid IT that ensure modernized and efficient eligibility systems that produce accurate and timely eligibility determinations and that can interface seamlessly with the Exchange operating in that state. In all states, including those that do not proceed with the expansion, state eligibility systems must be able to electronically pass accounts between the Exchange (whether state-based or federally-facilitated) in order to facilitate seamless coordination. In addition, the systems must be able to support a single streamlined application for coverage among insurance affordability programs, support Modified Adjusted Gross Income (MAGI)-based eligibility determinations; and must support new renewal processes and connections for data-driven, electronic verifications as described in the Medicaid eligibility final rule issued March 23, 2012 (available at http://www.gpo.gov/fdsys/pkg/FR-2012-03- 23/pdf/2012-6560.pdf ).
States are not required to "build in" programming for the new adult group. However, a state that conforms to the Standards and Conditions for Medicaid IT (particularly modular design and separation of business rules from core programming) will be able to quickly and efficiently support enrollment for the expansion population. In addition, enhanced funding is available for states that wish to explicitly "build in" placeholder programming for the new adult group now to provide for future flexibility.

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FAQ ID:93216

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