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Medicaid CHIP in 2014: A Simple Seamless Path to Affordable Coverage

Simple, Seamless and Affordable Coverage. August, 2011 Medicaid Eligibility NPRM Expands eligibility to 133% FPL for all individuals under age 65Provides a State option for coverage beyond 133% FPLSimplifies eligibility by consolidating certain eligibility categories. 2. Determining Eligibility Based on MAGI.

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Medicaid CHIP in 2014: A Simple Seamless Path to Affordable Coverage

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    1. Medicaid & CHIP in 2014: A Simple Seamless Path to Affordable Coverage 1

    2. Simple, Seamless and Affordable Coverage August, 2011 Medicaid Eligibility NPRM Expands eligibility to 133% FPL for all individuals under age 65 Provides a State option for coverage beyond 133% FPL Simplifies eligibility by consolidating certain eligibility categories 2

    3. Determining Eligibility Based on MAGI Section 2002 of the Affordable Care Act creates a new section 1902(e)(14) of the Social Security Act (the Act) Effective January 1, 2014 Medicaid financial eligibility for most individuals will be based on Modified Adjusted Gross Income (MAGI) Medicaid financial eligibility for eligibility groups for aged, blind, or disabled (ABD) individuals will still be based on SSI income and resource methodologies. 3

    4. Eligibility Expansion to 133% FPL New coverage under the “Adult Group” effective January 1, 2014: Section 2001(a) of the Affordable Care Act adds new section 1902(a)(10)(A)(i)(VIII) of the Act as mandatory coverage. The August NPRM proposes a new 42 CFR 435.119 for coverage of the Adult Group. 4

    5. Adult Group – New Coverage to 133% FPL The Adult Group will cover individuals with MAGI household income no more than 133% FPL, after deducting a 5% FPL general disregard. Included are individuals who are: Aged 19 to 64 (including children aged 19 or 20 but not children under 19 and not aged individuals); Not pregnant; Not Medicare eligible; and Not otherwise eligible for and enrolled in mandatory coverage. 5

    6. Adult Group – New Coverage to 133% FPL (cont.) A parent or other caretaker relative living with dependent child is not covered under the Adult Group unless the child is enrolled in Medicaid, CHIP, or other minimum essential coverage (defined in the Internal Revenue Code and regulations). 6

    7. New Optional Coverage Above 133% FPL New optional coverage for individuals above 133% FPL, effective January 1, 2014: Section 2001(e) of the Affordable Care Act added new section 1902(a)(10)(A)(ii)(XX). The August NPRM proposed a new 42 CFR 435.218 for coverage of this group. States may use this new optional group to provide coverage for individuals above 133% FPL. 7

    8. New Optional Coverage Above 133% FPL (cont.) This group covers individuals with MAGI household income that exceeds133% FPL. A State electing to cover this group establishes the income standard. In the August NPRM, there is no maximum standard proposed for this group. Higher income individuals may not be covered without covering lower income individuals. 8

    9. New Optional Coverage Above 133% FPL (cont.) Includes individuals who are: Under age 65 (not aged), with no minimum age; Pregnant; Medicare-eligible; and Not otherwise eligible for and enrolled in mandatory or optional coverage based on information available from the application. 9

    10. New Optional Coverage Above 133% FPL (cont.) A State is not required to determine whether an individual would be eligible for another eligibility group, unless such determination can be made based only on information provided on the application. Individuals may be enrolled in this group even if they appear to be eligible as medically needy. 10

    11. New Optional Coverage Above 133% FPL (cont.) A State may not limit coverage under this group to certain target populations. A State may elect to phase in coverage of this group by population and/or income limit. 11

    12. New Optional Coverage Above 133% FPL (cont.) A parent or other caretaker relative living with dependent child is not covered under this group unless the child is enrolled in Medicaid, CHIP, or other minimum essential coverage. Individuals in this group may not be enrolled mandatorily in benchmark or benchmark-equivalent coverage 12

    13. Simplification of Medicaid Eligibility In the August NPRM we are proposing to streamline and consolidate Medicaid eligibility for : Parents/caretaker relatives, Pregnant women; and Children. 13

    14. Simplification of Medicaid Eligibility (cont.) Consolidates multiple mandatory and optional eligibility groups into 3 categories: Parents and Caretaker Relatives: 42 CFR 435.110 Pregnant Women: 42 CFR 435.116 Children under age 19: 42 CFR 435.118 14

    15. Section 1931 Low-Income Families Section 1931 of the Act requires States to cover low-income families, including parents and other caretaker relatives (P/CRs), pregnant women, and minor, dependent children. We must retain that mandatory coverage. 15

    16. Section 1931 Low-Income Families (cont.) We must retain the following definitions for 1931: “Dependent child”: under age 18, or age 18 and a full-time student, and deprived of parental support because of at least one parent’s death, absence from home, or unemployment. “Caretaker relative”: a relative of a “dependent child” by blood, adoption, or marriage with whom the child lives, who assumes primary responsibility for the child’s care. 16

    17. 42 CFR 435.110 Parents and Other Caretaker Relatives §435.110: Parents and other caretaker relatives, and if applicable, the P/CR’s spouse MAGI-based household income is at or below the State’s approved income standard. A State specifies an applicable MAGI standard for P/CRs between the minimum and maximum standards specified in the NPRM As for all MAGI determinations, there will be no resource test. 17

    18. 42 CFR 435.116 Pregnant Women We are proposing to cover pregnant women under §435.116. A pregnant woman includes a woman during pregnancy and the post partum period. MAGI-based household income is at or below the income standard approved for this group. A State specifies its applicable MAGI standard for pregnant women between the specified minimum and maximum standards. 18

    19. 42 CFR 435.116 Pregnant Women (cont.) We are proposing to consolidate under §435.116 six AFDC-related mandatory and optional eligibility groups for pregnant women: 1931 low-income families for pregnant women in their third trimester with no dependent children; 1902(a)(10)(A)(i)(III) Qualified Pregnant Women; 1902(a)(10)(A)(i)(IV) mandatory poverty-level related pregnant women; 19

    20. 42 CFR 435.116 Pregnant Women (cont.) 1902(a)(10)(A)(ii)(I) optional pregnant women financially eligible for AFDC; 1902(a)(10)(A)(ii)(IV) optional pregnant women who would be financially eligible for AFDC if not institutionalized; and 1902(a)(10)(A)(ii)(IX) optional poverty-level related pregnant women. 20

    21. 42 CFR 435.116 Pregnant Women (cont.) Benefits for pregnant women under §435.116: States will retain the current flexibility to provide full coverage for all mandatory and optional services covered under the Medicaid State plan To all pregnant women, or Only to women whose income does not exceed a specified standard States have the option to cover certain enhanced pregnancy-related services, as specified at §440.250(p) 21

    22. 42 CFR 435.118 Children under Age 19 We are proposing to cover under §435.118 infants and children under age 19 whose MAGI-based household income is at or below the applicable income standard approved under this group for infants under age 1, children aged 1 to 5, or children aged 6 to 18. 22

    23. 42 CFR 435.118 Children under Age 19 We are proposing to consolidate under §435.118 seven AFDC-related mandatory and optional eligibility groups for children under age 19: 1902(a)(10)(A)(i)(VI) mandatory poverty-level related children aged 1 to 5; 1931 low-income families; 1902(a)(10)(A)(i)(III) Qualified Children; 23

    24. 42 CFR 435.118 Children under Age 19 1902(a)(10)(A)(i)(IV) mandatory poverty-level related infants; 1902(a)(10)(A)(i)(VII) mandatory poverty-level related children aged 6 to 18; 1902(a)(10)(A)(ii)(IV) Optional children who would be financially eligible for AFDC if not institutionalized; and 1902(a)(10)(A)(ii)(IX) Optional poverty-level related infants. 24

    25. 42 CFR 435.118 Children under Age 19 (cont.) Effective January 1, 2014, the Affordable Care Act increases the income standard for mandatory poverty-level related children aged 6 to18 eligible under section from 100% to 133% FPL. This is consistent with the minimum income standard for the poverty-level related children under age 6 and pregnant women. 25

    26. 42 CFR 435.118 Children under Age 19 (cont.) Each State will establish its applicable MAGI standard for each age group of children under age 19 between the minimum and maximum standards specified in the rule. Note that MOE remains in effect for children until September 30, 2019. 26

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