Frequently Asked Questions

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93111

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93116

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93121

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB)

FAQ ID:93126

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

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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93131

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93136

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93141

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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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93151

Coverage under section 1931 of the Act was not repealed with the ACA and will remain in effect in 2014. As noted in the table above, eligibility for parents and caretaker relatives under section 1931 is implemented at section 435.110 of the regulations; eligibility for pregnant women under section 1931 is implemented at section 435.116 and eligibility for children at section 435.118. TMA under section 1925 of the Act will sunset on December 31, 2012, unless extended by Congress. If Congress elects to extend section 1925 of the Act beyond December 31, 2013, States will need to provide TMA to eligible individuals as set forth in their approved State plans. Note that the 4-month extension for individuals losing eligibility under section 1931 of the Act due to increased earnings or hours of work (see sections 1902(e)(1)(A) and 1931(c)(2) of the Act), and the 4-month extension of eligibility for individuals losing eligibility due to increased spousal support (see section 1931(c)(1) of the Act) do not have a sunset date and would therefore still apply in 2014 unless repealed by Congress. The extension of eligibility for individuals losing coverage under section 1931 due to increased child support will no longer be relevant in 2014, as child support is not counted as income under MAGI-based methodologies.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93156

Yes. People with disabilities or who need long term care services and supports may qualify under the new adult group in 2014 if they meet the MAGI-based eligibility standards for that group. In addition, under the final eligibility and enrollment rule, eligibility for the new adult group based on MAGI does not preclude eligibility for coverage under an optional group that might be otherwise excepted from MAGI methods. Individuals with MAGI-based income up to 133% of the federal poverty level who meet the criteria for the adult group but who need long term services and supports, can choose to enroll in an optional group that better meets their needs, and they can move from the adult group to the optional eligibility group at any time, if eligible. Individuals found eligible for the new adult group based on MAGI, but who appear on the application to be potentially eligible for Medicaid on a basis other than MAGI, will be offered a more thorough eligibility determination so that they can have this option.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 81.8 KB)

FAQ ID:93161