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
The U.S. Office of Personal Management released a proposed rule implementing the Multi-State Plan Program on November 30, 2012. To ensure that the Multi-State Plans are competing on a level playing field with other plans in the marketplace, the proposed regulation largely defers to state insurance law and the standards promulgated by HHS and states related to qualified health plans. Under the proposal, Multi-State Plans will be evaluated based largely on the same criteria as other qualified health plans operating in Exchanges. The few areas in which the Office of Personal Management proposes different regulatory standards from those applicable to qualified health plans are areas where the Office of Personal Management has extensive experience through its administration of the Federal Employees Health Benefits Program. However, in order to ensure that these few differences will not create any unfair advantages, the Office of Personal Management seeks comment from states and other stakeholders on these proposals. The regulation appeared in the Federal Register on December 5, 2012, and the comment period runs through January 4, 2013.
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Yes. HHS has received questions about whether a state could allow an issuer that contracts with a state Medicaid agency as a Medicaid managed care organization to offer qualified health plans in the Exchange on a limited-enrollment basis to certain populations. This type of limited offering would permit the qualified health plan to serve as a "bridge" plan between Medicaid/CHIP coverage and private insurance. This would allow individuals transitioning from Medicaid or CHIP coverage to the Exchange to stay with the same issuer and provider network, and for family members to be covered by a single issuer with the same provider network. This approach is intended to promote continuity of coverage between Medicaid or CHIP and the Exchange.
In general, an Exchange may allow an issuer with a state Medicaid managed care organization contract to offer a qualified health plan as a Medicaid bridge plan under the following terms:
- The state must ensure that the health insurance issuer complies with applicable laws, and in particular with section 2702 of the Public Health Service Act. Consistent with section 2702(c) of the Public Health Service Act, a health plan whose provider network reaches capacity may deny new enrollment generally while continuing to permit limited enrollment of certain individuals in order to fulfill obligations to existing group contract holders and enrollees. Therefore, if the issuer demonstrates that the provider network serving the Medicaid managed care organization and bridge plan has sufficient capacity only to provide adequate services to bridge plan eligible individuals and existing Medicaid and/or CHIP eligible enrollees, the bridge plan could generally be closed to other new enrollment. However, in order to permit additional enrollment to be limited to bridge plan eligible individuals, the state must ensure there is a legally binding contractual obligation in place requiring the Medicaid managed care organization issuer to provide such coverage to these individuals. We note that any such contract would need to have provisions to prevent cost-shifting from the non-Medicaid/CHIP population to the Medicaid/CHIP population. We also note that the guaranteed availability provision of section 2702 of the Public Health Service Act is an important protection that provides consumer access to the individual and small group markets. Accordingly, we plan to construe narrowly the network capacity exception to the general guaranteed issue requirement.
- The Exchange must ensure that a bridge plan offered by a Medicaid managed care organization meets the qualified health plan certification requirements, and that having the Medicaid managed care organization offer the bridge plan is in the interest of consumers.
- As part of considering whether to certify a bridge plan as a qualified health plan, the Exchange must ensure that bridge plan eligible individuals are not disadvantaged in terms of the buying power of their advance payments of premium tax credits.
- The Exchange must accurately identify bridge plan eligible consumers, and convey to the consumer his or her qualified health plan coverage options.
- The Exchange must provide information on bridge plan eligible individuals to the federal government, as it will for any other individuals who are eligible for qualified health plans on the Exchange, to support the administration of advance payments of premium tax credits. This will be done using the same mechanism that will be in place for the larger Exchange population.
Successful implementation of a Medicaid bridge plan will involve a high degree of coordination between the state Medicaid agency, department of insurance and the Exchange. States operating State-Based Exchanges will be best positioned to achieve the level of coordination needed to implement and support the offering of a Medicaid bridge plan on an Exchange. Additional guidance will be issued soon.
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Under the Affordable Care Act, coverage for persons under the Pre-Existing Condition Insurance Plan program (whether federally-run or state-run in a state) will generally not extend beyond January 1, 2014, which is when all individuals will be able to access coverage without any pre-existing condition exclusions in the individual market. The transitional reinsurance program is expected to help stabilize premiums in the individual market by reimbursing issuers who enroll high cost individuals, such as those currently enrolled in the Pre-Existing Condition Insurance Plan, as they enter that market.
In the notice of proposed rulemaking on the health insurance market rules (77 Fed. Reg. 70584; November 26, 2012), we noted that we are exploring ways in which states could continue to run their existing high risk pools (i.e., separate from the Pre-Existing Condition Insurance Pool program) beyond 2014.
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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.
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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-systems/medicaid-eligibility-enrollment-toolkit.
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-systems/medicaid-enterprise-reuse.
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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.
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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.
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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.
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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.
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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