How will the new MAGI rules work?
The state will look at the individual's modified adjusted gross income, deduct 5%, which the law provides as a standard disregard, and compare that income to the new standard.
How were the new MAGI-based income standards set?
Based on guidance issued in December 2012 (PDF, 177.59 KB), CMS worked with states to set their new standards. Most states used a model that determines the average value of the disregards a state had in place and then added that amount to the old standard to create the new eligibility levels.
Will any individuals lose coverage as a result of the new MAGI-based income methodology?
No one loses coverage as a result of converting to MAGI rules, but, in states that don't adopt the new adult eligibility group, it is possible that some individuals will lose coverage.
It looks like in some states CHIP has gotten smaller; do the new MAGI rules result in smaller CHIP programs?
No, the change to MAGI does not affect the size of CHIP Programs.
Do the new MAGI standards mean that more children will move from CHIP to Medicaid?
No, the number of children moving from CHIP to Medicaid is not affected by the change to MAGI.
Under the law, those states that cover children ages 6-18 with incomes between 100% and 133% of the FPL in CHIP will be transitioning these children to Medicaid so that children under 133% of the FPL, regardless of their age, are eligible for the same coverage program (some states will continue to have different, higher income standards for younger children). The change to MAGI standards does not change the number of children who will move from CHIP to Medicaid.
With regards to MAGI, can states that want to have a "rounded" number for their eligibility standards do so or must they stay with the converted standards?
Yes, states can adjust their standards within certain limits established by law.
States can adjust both their adult standards (e.g., for pregnant women) and their children standards, as long as they do not reduce eligibility levels below minimum standards established by the law. CMS can advise states of their options.
What data should my state provide to the Centers for Medicare & Medicaid Services (CMS) for the annual Upper Payment Limit demonstrations?
Effective state fiscal year 2020, each state must submit a complete data set of payments to Medicaid providers, including providers paid at cost, as well as critical access hospitals. This would require states to submit cost and payment data to CMS that previously was not requested.
Can a state type information and data into unlocked fields in the Upper Payment Limit
Yes. Mapping data, through V-Look-ups, for example, is a much easier and consistent process for current and future UPL submissions. However, a state may choose to type information and data into unlocked fields in the UPL templates. When a state chooses to input data directly (not through a V-Look-up) into the template, it still must provide the supporting documentation with the source data. Additionally, the state should explain how it mapped data from the supporting documentation into the template.
When a facility has been in operation for the dates of service covered by the Upper Payment Limit (UPL) demonstration, can a state demonstrate the UPL by using less than 12 months of data?
In accordance with Medicare cost reporting, the state must use 12 months of cost data reported by each facility. With regard to payment data, the state should use actual amounts, to the extent available, then calculate a claims completion factor based on historic utilization. The state’s UPL submission must include an explanation of its methodology to estimate payments. The use of a claims completion factor provides a reasonable estimate of the amount that Medicare would pay for these services, consistent with the UPL as defined at 42 CFR 447.272.
Our state included dental services along with physician (non-dental) services in our state's Upper Payment
Dental services are not covered under Medicare, which means the state may not compare Medicaid rates for comparable dental services for the Medicare Equivalent of the ACR. The state may calculate a dental ACR in order to make supplemental payments to dental services providers and continue to calculate the Medicare Equivalent of the ACR for other services covered by Medicare. The state should submit two separate ACR demonstrations, one for dental services and one for physician (non-dental) services.