Frequently Asked Questions

"Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment Final Rule" (CMS-2334-F), published in the Federal Register on 7/15/2013, conformed the regulatory definition of preventive services at § 440.130(c) with the statute relating to the issue of who can be providers of preventive services. Per the final rule, effective 1/1/2014, preventive services may be recommended by a physician or other licensed practitioner. Therefore, unlicensed practitioners will be able to furnish preventive services (including the services mentioned in section 4106), based on the recommendation of a physician or other licensed practitioner, according to the provider qualifications established by each respective state, within broad federal parameters. In order for states to receive the one percentage point federal medical assistance percentage (FMAP) increase for unlicensed practitioners, it is likely that a state plan amendment updating section (13)(c) of the state plan will be necessary. Please refer to the preventive service CMCS Informational Bulletin issued on November 27, 2013 for additional information regarding adding unlicensed practitioners to the preventive services section of the state plan.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91676

While section 4106 of the Affordable Care Act states that USPSTF grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and their administration must be covered to secure the one percentage point FMAP increase, it is incumbent upon state Medicaid agencies to continue to work with, and communicate to, providers concerning state-specific systems and appropriate codes. The information provided by the American Medical Association in the below link (the CPT Code Pocket Guide: Preventive services with cost-sharing waived) can be used as a starting point in creating a cross-walk from the USPSTF and ACIP recommended codes, but it is not all-inclusive.

In addition, the October 2012 State Health Official (SHO) letter, gave the below web site address for HCPCS codes effective for service dates on or after January 1, 2012, and contacts within CMS for questions regarding HCPCS codes.

http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html 

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91686

While there is no deadline given in the provision for states to create public awareness campaigns to inform Medicaid beneficiaries of the preventive services covered in their state, CMS looks forward to partnering with states to develop innovative approaches. CMS is required to prepare a periodic Report to Congress including "summaries of the states' efforts to increase awareness of coverage of obesity-related services," and the next report will be submitted by January 1, 2014. As such, CMS is gathering information about states' efforts to inform the 2014 report. States may email MedicaidCHIPPrevention@cms.hhs.gov to submit information about preventive and obesity-related services public awareness efforts in their communities.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91491

Yes, a state may submit a SPA at any time. The one percentage point increase in federal medical assistance percentage (FMAP) per the requirements outlined in section 4106 of the Affordable Care Act does not have an end date.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91511

It's a new, simpler way to determine eligibility for Medicaid and CHIP.

The Affordable Care Act provides new simplified method for calculating income eligibility for Medicaid, CHIP and financial assistance available through the health insurance Marketplace. This new method calculates eligibility for all programs based on what is called modified adjusted gross income (MAGI). By using one set of income eligibility rules across all insurance affordability programs, the new law makes it easier for people to apply for health coverage through one application and enroll in the appropriate program. MAGI will replace the current process for calculating Medicaid eligibility that is in place today, which uses income deductions (known as "disregards") that are different in each state and often differ by eligibility group.

FAQ ID:92461

The new rules apply to most people who are eligible for Medicaid and Chip, but not the elderly or people who qualify based on a disability.

For coverage effective January 2014, MAGI will be the basis for determining both Medicaid and CHIP eligibility for children, pregnant women, parents and the adults enrolled under the new adult eligibility group created by the ACA (in states that adopt that eligibility group.) Individuals age 65 and older and those who qualify for Medicaid based on disability are not affected by the new rules.

FAQ ID:92466

Yes. A state's decision whether or not to extend Medicaid coverage for low-income adults in 2014 is not related to the use of MAGI. MAGI rules simplify the eligibility rules and promote coordination between Medicaid and CHIP and coverage available through the Marketplace; coordination will be important for consumers in all states regardless of a state's decision on Medicaid eligibility for low-income adults.

FAQ ID:92471

The eligibility standards (where there's been no expansion) are not any higher than the old standards; they are expressed in a different way (gross versus net).

In the past, Medicaid and CHIP eligibility used a combination of an income eligibility standard--often expressed as a percentage of the Federal Poverty Level (FPL)--and a series of deductions (known as "disregards" that were like footnotes or 'below the line' adjustments to income and were determined by each state. The new way of calculating eligibility based on MAGI translates that two-part process into a one step process using an income standard that incorporates the 'below the line' deductions. This makes the new standard appear higher than the old one (e.g. from 185% of the FPL to 193% of the FPL for pregnant women). In effect, however, the new income standard represents what the state's old two-step process would have resulted in, just expressed in a different way.

FAQ ID:92476

No, overall the new methodology does not change the number of people eligible for Medicaid. The MAGI-based standard will result in approximately the same number of people being eligible under the new standard as would have been eligible under the old standard. However, there may be some differences in which people will qualify--or not qualify--depending on how they might have fared under the old system (with deductions and disregards).

FAQ ID:92481

Before MAGI, if a state's income limit was 100% of the FPL--the state would first look at the person's gross income, then subtract out (for example) 30% of their earned income and an amount they spend on childcare as work-related expense deductions and then compare that net income to 100% of the FPL. This means that under the pre-MAGI rules, in a state with an income eligibility limit of 100% of the FPL, a person with income over 100% of the FPL can qualify for Medicaid (because of the deductions and disregards).

FAQ ID:92486