Frequently Asked Questions

Self-attestation is permitted for all factors of eligibility, except as required by law (i.e. citizenship and immigration status). States must accept self-attestation of pregnancy, unless information provided is not reasonably compatible with other information in the State's files.

Supplemental Links:

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

Under the Affordable Care Act, an Expansion State is one that had eligibility standards for parents and nonpregnant childless adults (under either the State plan or a demonstration project) to at least 100 percent of the FPL as of the date of enactment of the Affordable Care Act. Specifically, a State is an expansion State if, on March 23, 2010, the State offered health benefits coverage Statewide to parents and non-pregnant, childless adults whose income is at least 100 percent of the poverty line, that includes inpatient hospital services, is not dependent on access to employer coverage, employer contribution, or employment and is not limited to premium assistance, hospital-only benefits, a high deductible health plan, or alternative benefits under a demonstration program authorized under section 1938 of the act. A State that offers health benefits coverage to only parents or only non-pregnant childless adults described in preceding sentence will not be considered to be an expansion State; both groups must have been covered as described above.

The law established a special Federal medical assistance percentage (FMAP) for expansion States. Expansion States are able to claim a special FMAP for the non-pregnant childless adults who are not "newly eligible." These States can also claim the enhanced FMAP for individuals who are "newly eligible" in 2014. CMS is in the process of a 50-State review of State coverage as of March 23, 2010.

Supplemental Links:

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

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.

Supplemental Links:

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

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.

Supplemental Links:

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

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.

Supplemental Links:

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

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.

Supplemental Links:

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

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.

Supplemental Links:

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

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

Supplemental Links:

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

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.

Supplemental Links:

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

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.

Supplemental Links:

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