Frequently Asked Questions

In 2014, some low-income children will be covered by Medicaid or CHIP while their parents obtain coverage on the Exchange with advance payments of the premium tax credit. Premium assistance, an option under current law, provides an opportunity for state Medicaid and CHIP programs to offer coverage to such families through the same coverage source, even if supported by different payers. Under Medicaid and CHIP statutory options, states can use federal and state Medicaid and CHIP funds to deliver Medicaid and CHIP coverage through the purchase of private health insurance. Most commonly, states have used premium assistance to help Medicaid/CHIP eligible families pay for available employer-based coverage that the state determines is cost effective. There are cost sharing assistance and benefit wrap-around coverage requirements, to the extent that the insurance purchased with Medicaid and/or CHIP funds does not meet Medicaid or CHIP standards. In both Medicaid and CHIP, premium assistance is authorized for group health coverage and, under some authorities, for health plans in the individual market, which, in 2014 would include qualified health plans available through the Exchange. Please note that advance payments of the premium tax credit and cost-sharing reductions are not available for an individual who is eligible for Medicaid or CHIP. The statutory authorities that permit use of title XIX or title XXI funds to be used for premium assistance for health plans in the individual market, including qualified health plans in the Exchange, are sections 1905(a) and 2105(c)(3) of the Social Security Act.

For example, beginning in 2014, when a child is eligible for Medicaid/CHIP and the parent is enrolled in a qualified health plan through the Exchange, a state Medicaid or CHIP program could use existing premium assistance authority to purchase coverage for a Medicaid or CHIP-eligible child through that qualified health plan. The premium tax credit would not be available to help cover the cost of coverage for these children. As noted above, with respect to the children, the state would adhere to federal standards for premium assistance, including providing wrap-around benefits, cost sharing assistance, and demonstrating cost-effectiveness, as appropriate. A State-Based Exchange may be able to support such an option, and in states where a Federally-Facilitated Exchange is operating, a State Medicaid or CHIP agency may be able to take this approach by making arrangements with qualified health plans to pay premiums for individuals. We will be working with states interested in this option to consider how the state Medicaid and CHIP agency can coordinate with the Exchange to establish and simplify premium assistance arrangements.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)

FAQ ID:94631

The Affordable Care Act envisions and directs that there be a coordinated system for making eligibility determinations between Medicaid, CHIP and the Exchange to avoid gaps in coverage as individuals' income fluctuates. Smooth eligibility transitions will not necessarily prevent people from having to select a new plan and/or provider when they lose eligibility for one insurance affordability program and gain eligibility for another. The extent to which such changes in plans and providers occur will depend on whether and to what degree plans participate in both the Exchange and in Medicaid and CHIP, and the networks in such plans.

Premium assistance can help address this issue, while encouraging robust plan participation in Medicaid, CHIP, and the Exchange. As discussed above, this option permits state Medicaid or CHIP programs to use premium assistance to enroll a Medicaid or CHIP eligible individual or family in a qualified health plan through the Exchange. States may be most interested in this option for families close to the top of the Medicaid income limit. Under this arrangement, if a family's income changes such that some or all members of the family become ineligible for Medicaid or CHIP and eligible for a premium tax credit to help cover the cost of a qualified health plan through the Exchange, it would be less likely that members moving into Exchange coverage would need to change plans or providers.

Similarly, premium assistance could help increase the likelihood that individuals moving from Exchange coverage into Medicaid or CHIP may remain in the same qualified health plan in which they had been enrolled through the Exchange.

As discussed above, premium assistance options in Medicaid and CHIP are subject to federal standards related to wrap around benefits, cost sharing and cost effectiveness. There may also be an opportunity for states to promote continuity of coverage through "bridge plans" as described earlier.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)

FAQ ID:94636

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.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93216

CMS has developed the Medicaid Eligibility and Enrollment Toolkit (MEET) to provide guidance for states that are conducting E&E systems projects. The MEET is available at https://www.medicaid.gov/medicaid/data-and-systems/meet/index.html.

Also, various artifacts developed by states are posted in a shared environment for reuse by others. These artifacts can be used to help jump-start projects. More information on reuse, including access to the reuse repository, is available at https://www.medicaid.gov/medicaid/data-and-systems/reuse/index.html.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93226

There is no deadline by which states need to decide on the Medicaid expansion. We understand that there are many considerations involved in this decision, and CMS stands ready to work with states on their individual timetables. Regardless of the expansion, every state that uses the Federally Facilitated Exchange will need to support coordination between the Medicaid and CHIP programs and the FFE and otherwise comply with the new MAGI rules as well as the application, renewal and verification procedures 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). We will be working with each state to ensure that the appropriate business rules are accommodated and tested, and the necessary electronic account handoffs are in place, before the FFE is operational and the new Medicaid rules are in effect. We are continuing to provide more guidance and information on these issues as part of the FFE manual and MOU process as well as through our SOTA calls. We are also establishing a state- to- FFE change process to help manage changes in policies that a state may make over time; a state that decides later to proceed with expansion will be accommodated within that process.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93236

As previously stated in a letter from the Secretary to the nation's governors, the Supreme Court held that a state may not lose federal funding for its existing Medicaid program if the state chooses not to participate in the expansion of Medicaid eligibility for low-income adults. The Court's decision did not affect other provisions of the law. State Medicaid and CHIP programs will need to coordinate with the Federally-facilitated Exchange, regardless of a state's decision to proceed with expansion. States will need to be part of the seamless system for people to apply for all coverage programs; and will need to coordinate eligibility with the new insurance affordability programs. These provisions have relevance regardless of whether a state chooses to participate in the expansion for low-income adults.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93246

The FFE's role is the same whether or not a state implements the Medicaid expansion for low-income adults. The FFE will still make MAGI-based determinations or assessments of eligibility for Medicaid and CHIP and will assess eligibility for premium tax credits and cost sharing. The FFE will apply the state's eligibility levels for Medicaid/CHIP when it makes the Medicaid determination or assessment. In addition, as established in the Exchange and Medicaid/CHIP eligibility final rules, the FFE will electronically transfer accounts for individuals who are either determined or assessed as eligible for Medicaid and CHIP (it is a state option whether to have the FFE determine or assess eligibility) for further evaluation/action.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93256

The federal hub will provide data verification services to any state-based exchange and to the Medicaid and CHIP program without regard to whether a state has adopted the low-income adult expansion. Consistent with the regulations issued on March 23, 2012, state Medicaid and CHIP programs must rely on the HUB for certain information; this provision applies without regard to whether a state has adopted the Medicaid expansion for low-income adults.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93261

The Federal data services hub will provide the following services on Day 1. CMS is also pursuing data sources for additional verifications through the Federal data services hub and will keep states updated as they are confirmed:

• Social Security Number (SSN) verification via the Social Security Administration (SSA)
• Citizenship verification via SSA or the Department of Homeland Security (DHS) when relevant
• Incarceration verification via SSA
• Title II benefit income information via SSA (monthly and annual amounts)
• Quarters of coverage information via SSA
• MAGI income information from the Internal Revenue Service (IRS)
• Max APTC from IRS
• Immigration status verification via DHS, as well as a translation to indicators for lawful presence, qualified non-citizen, and five year bar status.
• Public minimum essential coverage (MEC) verification from Federal agencies

FAQ ID:93266

No. We will not charge state-based exchanges (SBEs) or Medicaid/CHIP agencies for the Federal data hub services or underlying data.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)

FAQ ID:93271