inv-01: MAGI-based adult eligibility
inv-01: MAGI-based adult eligibility — Proposed coverage rules for the new adult group and MAGI-based eligibility
ALL of the following
New adult group established at §435.119 for individuals age 19 (age 19 or older) through under age 65 with household income at or below 133% FPL based on MAGI methodologies (section 1902(a)(10)(A)(i)(VIII) of the Act).
Financial eligibility for the adult group is determined using MAGI methods as defined at proposed §435.603; no resource test applies for MAGI-based eligibility.
Individuals are ineligible under the adult group if they are otherwise mandatory eligible under section 1902(a)(10)(A)(i) and 42 CFR part 435 subpart B, except that in States using more restrictive criteria than SSI under §435.121 individuals potentially eligible under SSI may still qualify under the adult group if they meet the adult group criteria.
Parents and other caretaker relatives are included in the adult group but a State may only provide Medicaid to a parent/caretaker relative under the adult group if their dependent children under the applicable age are enrolled in Medicaid, CHIP, or otherwise have minimum essential coverage; the applicable child age is under 19 unless the State had elected higher ages under §435.222 as of March 23, 2010.
Proposed §435.218 provides an optional group for individuals under 65 with MAGI above 133% FPL up to a State-established income standard approved in the State plan; States may phase-in coverage under a CMS-approved plan and must not provide higher-income coverage without covering lower-income individuals first.
inv-02: Eligibility coordination
inv-02: Eligibility coordination — Procedural and system requirements
ALL of the following
State Medicaid agencies must establish secure electronic interfaces and procedures to receive electronic accounts, application data, and eligibility findings from Exchanges and other insurance affordability programs, as required by §435.1200(d),(e),(f).
For individuals found eligible by the Exchange based on MAGI, the Medicaid agency must promptly furnish Medicaid benefits without undue delay and treat such determinations as if made by the agency itself, receiving the electronic account, application information, and any verified data (§435.1200(e)(1)-(2)).
When an individual is screened by another program as potentially Medicaid-eligible, the Medicaid agency must accept the electronic account, avoid requesting duplicate information already in the account, determine eligibility per §435.911(c), and notify the originating program of the determination (§435.1200(f)).
For applicants not eligible under MAGI-based screening, the agency must collect additional information to determine eligibility on other bases and simultaneously assess potential eligibility for other insurance affordability programs; electronic transfers of accounts must include all application and verification data (§435.911(c)(2); §435.1200(g)).
inv-03: Adult group (§435.119) — Mandatory adult group coverage
inv-03: Adult group (§435.119) — Mandatory adult group coverage
ALL of the following
Mandatory coverage under §435.119 for individuals age 19 through 64 (age 19 or older and under age 65) who are not pregnant, not entitled to Medicare Part A or B, not otherwise mandatorily eligible under subpart B, and have household income at or below 133% FPL (MAGI-based).
The agency must provide Medicaid to such individuals; coverage of dependent children imposes the limitation that parents/caretakers may only be covered if dependent children are enrolled in Medicaid/CHIP or other minimum essential coverage, with the child age threshold per §435.119(c).
inv-04: Optional group (§435.218) — Optional coverage above 133% FPL
inv-04: Optional group (§435.218) — Optional coverage above 133% FPL
ALL of the following
Proposed §435.218 creates an optional eligibility group allowing States to provide Medicaid to individuals under age 65 whose MAGI-based household income exceeds 133% FPL but does not exceed a State-established income standard approved in the State plan (section 1902(a)(10)(A)(ii)(XX)).
Eligibility criteria require individuals not be eligible for mandatory subpart B coverage and not be eligible/enrolled for optional subpart C coverage based on information available from the application; States may assume eligibility for this group unless another eligible group can be determined from application data without additional determinations (§435.218(b)).
States must not provide coverage to higher-income individuals under this optional group without also covering lower-income individuals, except as part of an approved phase-in plan (§435.218(b)(2)-(3)).
inv-05: MAGI-based core categories — MAGI-based parents/caretakers, pregnant women, and children
inv-05: MAGI-based core categories — MAGI-based parents/caretakers, pregnant women, and children
ALL of the following
Parents and other caretaker relatives: §435.110 continues mandatory coverage under sections 1931(b) and (d); States establish a MAGI-equivalent income standard in the State plan with specified minimums and maximums converted per guidance; income methods simplified to rely on MAGI-equivalent net countable standards (§435.110; see discussion at chunks 29,31).
Pregnant women: §435.116 consolidates pregnancy-related categories; States establish income standards with a minimum of 133% FPL (or higher island limits in effect Dec 19, 1989 up to 185% FPL) and a maximum the higher of the State's effective income level converted to MAGI-equivalent or 185% FPL; pregnancy coverage rules and verification rely primarily on attestation unless incompatible information is present (§435.116; §435.956(e)).
Infants and children under 19: §435.118 consolidates mandatory and optional child categories with minimum MAGI-based standards of 133% FPL (infants may have a higher historic standard up to 185%); States must set age-group income standards in the State plan and may not apply new income disregards for MAGI-based eligibility after Jan 1, 2014 (§435.118).
inv-06: MAGI-based coverage criteria — Coverage groups and income counting rules under MAGI-based methodologies.
inv-06: MAGI-based coverage criteria — Coverage groups and income counting rules under MAGI-based methodologies.
ALL of the following
MAGI methodologies implemented at §435.603 define household, family size, and income counting consistent with section 36B and 26 U.S.C. definitions; household income sums MAGI-based income of household members required to file under IRC §6012, with special rules for children who file but are not required to file (§435.603(b)-(d)).
Income counting rules at §435.603(e) generally codify section 36B rules to promote alignment across Medicaid, CHIP, and Exchanges, with specified treatments for child support, business depreciation, capital gains/losses, and other differences from pre-ACA Medicaid rules.
Transition rule: MAGI methodologies do not apply to individuals enrolled as of Jan 1, 2014 until the next regular redetermination after Dec 31, 2013 or March 31, 2014, whichever is later, if application of MAGI would otherwise cause loss of eligibility before that date (§435.603(a)(3)).
inv-07: COVERAGE CRITERIA — MAGI screening and subsequent evaluation process for applicants meeting nonfinancial criteria
inv-07: COVERAGE CRITERIA — MAGI screening and subsequent evaluation process for applicants meeting nonfinancial criteria
ALL of the following
MAGI Screen (§435.911): For every applicant who meets non-financial criteria, the agency must determine whether household income is at or below the applicable MAGI standard (at least 133% FPL or higher standards for certain groups); if yes, furnish Medicaid promptly without undue delay (§435.911(c)(1)).
If household income exceeds the applicable MAGI standard, the agency must collect additional information to determine eligibility on other bases (e.g., disability, Medicare assistance) and assess potential eligibility for other insurance affordability programs, facilitating transfers of electronic accounts as necessary (§435.911(c)(2); §435.1200(g)).
The MAGI screen aligns with Exchange proposed rules at 45 CFR 155.305(c); the Medicaid agency retains responsibility for determinations based on non-MAGI factors, though the State may arrange for the Exchange to undertake such determinations under specified procedures (§435.911; §435.1200(e)).
inv-08: Eligibility verification and renewal criteria — Verification and acceptance rules for eligibility determination and renewal.
inv-08: Eligibility verification and renewal criteria — Verification and acceptance rules for eligibility determination and renewal.
ALL of the following
Verification: Proposed subpart J revisions (§435.940–§435.956) emphasize reliance on electronic data sources and the Secretary-established electronic service (§435.949) to corroborate/verifiy income, citizenship, immigration, SSNs, and residency; States may accept self-attestation for most criteria except citizenship/immigration, and may rely on attestation for pregnancy and household composition absent incompatible information (§435.945–§435.956).
§435.948 requires agencies to request financial information (wages, self-employment, unearned income) from SWICA, IRS, SSA, state unemployment, PARIS, SNAP, and other programs when useful; if available via the Secretary's electronic service, agencies must obtain info through that service (§435.948–§435.949).
Periodic redetermination (§435.916): Eligibility under §435.911(c)(1) must be redetermined at least once every 12 months; agencies must redetermine without requiring beneficiary input if reliable information in the account or other current sources suffices, use pre-populated renewal forms with at least 30 days to respond when additional info is needed, and notify individuals of determinations without requiring signed returns for administrative renewals (§435.916).
inv-09: Coordinated eligibility and transfer procedures — Procedures for determining and transferring eligibility across programs and handling of individuals found ineligible or pending special determinations.
inv-09: Coordinated eligibility and transfer procedures — Procedures for determining and transferring eligibility across programs and handling of individuals found ineligible or pending special determinations.
ALL of the following
Coordination (§435.1200): Medicaid agencies must maintain websites supporting applications, renewals, and information access; websites must be accessible to persons with disabilities and limited English proficient individuals and support secure electronic transfer of applicant electronic accounts between programs (§435.1200(d)).
Transfer and acceptance of applications (§435.1200(f)): Agencies must promptly determine eligibility for individuals identified as potentially Medicaid-eligible by other programs, accept electronic accounts, avoid requesting already-obtained information, and notify originating programs of final determinations (§435.1200(f)).
Evaluation for other programs (§435.1200(g)): Individuals determined not eligible for Medicaid must be assessed for eligibility for premium tax credits, cost sharing reductions, and Exchange coverage, and their electronic accounts transferred promptly to the appropriate program; when determining eligibility on non-MAGI bases (e.g., disability), agencies must simultaneously assess Exchange eligibility and transfer accounts as needed (§435.1200(g)(1)-(2)).
inv-10: Eligibility and verification criteria — Financial eligibility and verification standards for CHIP and Medicaid under MAGI
inv-10: Eligibility and verification criteria — Financial eligibility and verification standards for CHIP and Medicaid under MAGI
ALL of the following
CHIP alignment: Effective Jan 1, 2014, CHIP agencies apply MAGI financial methodologies in §435.603 for determining financial eligibility for CHIP (§457.315), eliminating assets/resources in financial determinations and restricting income disregards to the 5% specified in section 1902(e)(14)(I) (§457.320; §457.315).
Verification standards for separate CHIP programs in proposed §457.380 mirror Medicaid and Exchange rules: residency and income verification aligned with §435.956 and §435.948; acceptance of self-attestation for pregnancy and household membership unless incompatible information exists; States may adopt reasonable verification procedures for other criteria (§457.380; §457.380(c)-(d)).
inv-11: Methodology options for allocating Newly Eligible FMAP — Proposed methodological approaches for determining expenditures claimable at the Newly Eligible FMAP
inv-11: Methodology options for allocating Newly Eligible FMAP — Proposed methodological approaches for determining expenditures claimable at the Newly Eligible FMAP
ALL of the following
States must choose one methodology for claiming the increased FMAP for newly eligible individuals as described in §433.10 and Subpart E (§433.206): (1) Apply eligibility thresholds and proxies (§433.208); (2) Conduct a statistically valid sample (§433.210); or (3) Use the CMS-established FMAP proportion rate (§433.212).
Choice requirements: States must submit the methodology to CMS for approval at least 2 years prior to implementation (except notify by Dec 31, 2012 for CY2014) and must use a chosen methodology for at least 3 consecutive years before changing (§433.206(b)).
Sampling and modeling options: CMS proposes threshold, modeling, or sampling approaches (and hybrids) to estimate the share of expenditures eligible for newly eligible FMAP; models may use MSIS, MEPS, and other data sources, with validation and potential sampling reconciliation beginning CY2016 (§433.210; chunks 144–147).
inv-12: Paperwork Reduction Act ICRs and estimated burdens — Information collection and recordkeeping requirements proposed under the PRA that States/CHIP agencies must implement
inv-12: Paperwork Reduction Act ICRs and estimated burdens — Information collection and recordkeeping requirements proposed under the PRA that States/CHIP agencies must implement
ALL of the following
The proposed rule contains numerous ICRs subject to PRA and OMB review including State plan submissions, choice of FMAP methodology, single streamlined application, collection of SSNs, revisions to CHIP reporting templates, verification and renewal processes, website functionality, and CMS-64 reporting (see list at chunk 151).
Estimated burdens: CMS provides detailed state-level and national estimates for hours and costs associated with verification agreements, renewals, recordkeeping, website development, ICRs regarding Web sites and renewal processing (see tables and narratives at chunks 153–160).
States are invited to comment on ICRs; CMS will submit supporting statements to OMB and requires OMB approval prior to effectiveness of collections (§III Collection of Information Requirements).'
inv-13: Proposed rule impacts and analyses — Summary stance and projected impacts of the proposed Medicaid eligibility and enrollment rule under the Affordable Care Act.
inv-13: Proposed rule impacts and analyses — Summary stance and projected impacts of the proposed Medicaid eligibility and enrollment rule under the Affordable Care Act.
ALL of the following
Need and intent: The regulation implements ACA provisions to expand and simplify Medicaid eligibility, coordinate with Exchanges and CHIP, reduce administrative burden, and extend increased FMAPs for newly eligible individuals (chunks 166–168).
Projected impacts: OACT estimates up to 24 million additional enrollees by 2016; CBO estimates ~16 million net increase; projected federal spending increases documented (OACT and CBO estimates) and varied participation assumptions acknowledged (chunks 167–168).
inv-14: Enhanced FMAP claiming criteria and methods — Methods and criteria for claiming enhanced FMAP for expenditures for newly eligible individuals
inv-14: Enhanced FMAP claiming criteria and methods — Methods and criteria for claiming enhanced FMAP for expenditures for newly eligible individuals
ALL of the following
§433.10 sets the increased FMAP schedule for newly eligible individuals (100% CY2014–2016, phasing down thereafter to 90% thereafter) and describes applicability to State expenditures per chosen methodology (§433.10(c)(6)).
States must implement one of the approved methodologies in §433.206 to determine expenditures claimable at the newly eligible FMAP and adhere to submission and timing requirements; CMS will publish State-specific rates if using CMS-established proportions (§433.206; §433.210; §433.212).
inv-15: Coverage and FMAP claiming criteria — Mandatory coverage groups and income standards established
inv-15: Coverage and FMAP claiming criteria — Mandatory coverage groups and income standards established
ALL of the following
The proposed rule revises mandatory coverage groups and income standards for parents/caretakers (§435.110), pregnant women (§435.116), children (§435.118), and the new adult group (§435.119), establishing MAGI-equivalent income standards and eliminating resource tests for MAGI-based eligibilities.
States must convert existing income standards to MAGI-equivalent levels per Secretary guidance and may no longer apply new income disregards for MAGI-based eligibility after Jan 1, 2014; higher coverage can be achieved through the optional group (§435.218) or CHIP (§457.320).
inv-16: Eligibility and application criteria — Eligibility categories and income standards described in these sections govern mandatory and optional Medicaid coverage
inv-16: Eligibility and application criteria — Eligibility categories and income standards described in these sections govern mandatory and optional Medicaid coverage
ALL of the following
Applications and assistance: States must provide availability of program information, application assistance, and accept single streamlined applications per proposed §§435.905–435.908 and §457.340; applications must support electronic submission and secure transfers between programs (§435.907; §457.340).
MAGI-based application processing: Exchanges and Medicaid use common MAGI methodologies; Exchange findings of potential Medicaid/CHIP eligibility must be transferred electronically and acted on promptly by the appropriate agency (§435.911; §435.1200).
inv-17: MAGI eligibility, verification, redetermination, and agency responsibilities — Eligibility determination and verification criteria and operational requirements for State Medicaid agencies.
inv-17: MAGI eligibility, verification, redetermination, and agency responsibilities — Eligibility determination and verification criteria and operational requirements for State Medicaid agencies.
ALL of the following
State responsibilities (§435.1200): certify criteria for Exchange determinations, maintain accessible websites, accept and process electronic accounts, provide prompt enrollment for Exchange-determined eligibles, and coordinate transfers and evaluations for other programs (§435.1200(c)-(g)).
Verification and redetermination: Use Secretary-established electronic service (§435.949) for verification where available; accept attestation for most non-financial criteria (except citizenship/immigration), reliance on electronic sources to minimize paper documentation; redetermine eligibility at least annually with administrative renewals where possible (§435.948–§435.956; §435.916).
inv-18: Inter-program eligibility transfer and processing — Procedures for providing Medicaid/CHIP to individuals found eligible by the Exchange or other programs and for screening/transferring applicant information.
inv-18: Inter-program eligibility transfer and processing — Procedures for providing Medicaid/CHIP to individuals found eligible by the Exchange or other programs and for screening/transferring applicant information.
ALL of the following
Exchange-to-Medicaid/CHIP transfers (§435.1200(e); §457.348(a)): States must accept exchange determinations, receive electronic accounts, and furnish Medicaid/CHIP promptly; agencies must not re-verify criteria already verified by the originating program.
Screening and transfer for ineligibles (§435.1200(g); §435.1200(f)): Individuals determined not eligible for Medicaid must be assessed for other insurance affordability programs and transferred electronically to Exchanges for potential premium tax credits or enrollment; similarly, CHIP agencies must accept Exchange findings for CHIP and transfer accounts among programs as needed (§435.1200(g); §457.348).
inv-19: CHIP income methodology and application process — Application, redetermination, and enrollment rules for separate CHIP programs aligned with Medicaid MAGI rules.
inv-19: CHIP income methodology and application process — Application, redetermination, and enrollment rules for separate CHIP programs aligned with Medicaid MAGI rules.
ALL of the following
CHIP MAGI application and enrollment (§457.340; §457.315): States must provide application assistance in person, by phone, and online; require SSNs for applicants per §435.907(e) and §457.340(b); determine CHIP financial eligibility using MAGI methodologies in §435.603 beginning Jan 1, 2014 (§457.315).
CHIP verification and renewals (§457.380; §457.343): Separate CHIP programs must align verification of residency and income with Medicaid rules (§435.956; §435.948), accept attestation for pregnancy and household composition unless incompatible information exists, and implement procedures to accept electronic accounts and determinations from Exchanges and other programs to promptly enroll children found eligible (§457.380; §457.343; §457.348).