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
Can a State claim enhanced FMAP for parents in the new adult group?
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.
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. 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)
How should a state that has a section 1915(c) home and community-based services waiver that includes individuals in the EPSDT age group and also individuals beyond their 21st birthday address the Autism Spectrum Disorder (ASD)-related services that are now available through the Medicaid state plan?
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.
- This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)
Does the 75 percent FFP apply to program integrity activities associated with eligibility and enrollment?
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.
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
I am looking for a dentist in my area who accepts Medicaid. How can I find one?
Use our dentist locator to find a dentist that accepts Medicaid.
Does the new mandatory EQR network adequacy validation activity have to be performed by the same EQRO that performs the other mandatory activities?
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).
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
When should MMIS and /or E&E milestone reviews be conducted?
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.
For E&E and MMIS, how often do the IV&V progress reports have to be submitted to CMS?
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.