Frequently Asked Questions

An assessment for IV&V analysis of a state's E&E system development effort will be required for APD projects that meet any of the criteria contained in federal regulations at 45 CFR 95.626(a). If CMS determines that the IV&V analysis is required for a state's system development effort, the provisions contained in federal regulations at 45 CFR 95.626(b) and (c) apply. Additional guidance is available in the Medicaid E&E Toolkit, available at https://www.medicaid.gov/medicaid/data-and-systems/meet/index.html.

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

Medicaid Budget Expenditure System/Children's Budget Expenditure System (MBES/CBES) has been modified to add new Medicaid Eligibility Determination System lines to the 64.10 Form series beginning with Quarter Ending March 31, 2011:

• 28A - DDI of Medicaid E&E systems/cost of in house activities - 90% FFP
• 28B - DDI of Medicaid E&E systems cost of private sector contractors - 90% FFP
• 28C - Operation of an approved Medicaid E&E system/cost of in-house activities - 75 % FFP
• 28D - Operation of an approved Medicaid E&E system/cost private sector contractors- 75% FFP

All transactional requests to the Federal data services hub shall be performed via web services. These services shall be invoked by State IT systems via application programming interfaces (API) or Web APIs that are accessed via secure Hypertext Transfer Protocol (HTTP) and shall be executed on the system hosting the requested services. The CMS web services shall accept request from trusted sources, perform the function based on the request, and return a response to the State system. CMS shall publish these web services in the CMS Service Catalog, which shall contain all services available to the states and the definitions of the standards that must be met to request the service and standard data format for the data provided when making the request and the data that shall be returned.

CMS is still determining the best mechanism for how batch and bulk data transactions will be designed and implemented. At this stage, CMS believes that there shall be a need to establish both web services and possibly alternate interfaces to meet batch and bulk data transaction requirements.

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

The process for making a MAGI-based eligibility determination is largely the same for all insurance affordability programs. The Affordable Care Act requires a single, streamlined application, accompanied by a similar set of business rules and verification processes, and an adjudication work flow that is largely identical between Exchanges, Medicaid and CHIP programs.

It is expected that State agencies that receive Federal funds from CMS to establish State-based Exchanges and provide for Medicaid and CHIP expansions coordinate efforts to produce a shared eligibility service or system that relies on a shared IT infrastructure and as such, cost allocate this service.

A shared eligibility service is not the same as one system. We define an eligibility service as a set of IT functions that produce an eligibility determination based upon MAGI.  The service incorporates an application, a set of verifications (for citizenship, income, residency, etc.) and business rules that together determine how much financial assistance a consumer should receive to acquire affordable health insurance.

While policies codified in final regulations allow legal authority for eligibility determinations to remain with state Medicaid agencies (for Medicaid) and Exchanges (for premium tax credits and cost-sharing reductions), the underlying business rules and processes are nearly identical, and should, to the maximum extent practical, rely upon a shared IT service(s) and infrastructure.

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

Yes. 1915 (c) waivers are optional programs that most States currently operate and can continue to operate. States interested in making changes to their 1915(c) waivers should contact their CMS Regional Office with specific questions.

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

Yes. CHIP enhanced FMAP will continue to be available for children whose income is greater than the Medicaid applicable income level (defined in section 457.301 and based on the 1997 Medicaid income standard for children), regardless of whether those children are enrolled in Medicaid or CHIP. This includes children who previously qualified for CHIP in a separate program and children whose family incomes are up to 133 percent of the Federal poverty level, and therefore will be newly eligible for Medicaid in 2014.

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

Yes. Section 2101(f) of the Affordable Care Act provides that States maintain coverage under a separate CHIP program for children who lose Medicaid eligibility due to the elimination of income disregards as a result of the conversion to MAGI. We anticipate that this provision will directly impact a relatively small number of children, and are committed to helping States implement this provision in a manner that is not unduly burdensome or costly and still protects the continuity of coverage for these children as required by statute.

For States with only Medicaid Expansion CHIPs, one approach is to create a separate CHIP that is substantively identical to the existing program, thereby creating the greatest continuity of coverage for the child, the least confusion for the family, and the most efficient operation for the state. For States with existing separate CHIPs, a State plan amendment assuring that these children will be covered through that program for as long as they qualify should be sufficient.

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

The agreement between Medicaid/CHIP agencies and Exchanges regarding coordination must be available to the Secretary upon request and will be subject to applicable disclosure laws, such as the Freedom of Information Act.

Supplemental Links:

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

States can work with the Federally-Facilitated Exchange (FFE) regarding Medicaid and CHIP eligibility determinations in one of two ways. The State may either establish an agreement whereby the FFE assesses applicants for Medicaid/CHIP eligibility based on MAGI and then transfers the applicants' electronic accounts to the State Medicaid or CHIP agency to complete the eligibility determination. Or the State may elect to accept MAGI-based eligibility determinations completed by the FFE as final determinations. Regardless of the approach, the process should be as seamless as possible for the applicant with most eligibility determinations completed in near real-time as specified in our eligibility final rule at 435.912.

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

The Exchange will utilize the State's Medicaid and CHIP eligibility rules for conducting both eligibility determinations and eligibility assessments. This will include application of the State's MAGI income standards and related eligibility rules for the MAGI population. The Exchange will also rely on a robust verification protocol that is consistent with Medicaid and CHIP regulations but which might not be the same protocol the State is otherwise using.

If a State accepts assessments of eligibility from the Federally-Facilitated Exchange (FFE) and chooses to make the final eligibility determinations itself, once an individual has been assessed as Medicaid/CHIP eligible, their electronic account would be transferred to the State Medicaid or CHIP agency, which will complete the eligibility determination. This process will include any additional verification required by the State that is consistent with the Federal verification regulations.

Supplemental Links:

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