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CRS report says states cannot yet change Medicaid eligibility

Posted on July 19, 2012 | Comments (2)

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The Congressional Research Services (CRS) published a memo saying that states cannot change Medicaid eligibility before 2014. The Affordable Care Act (ACA) requires states to maintain 2009 Medicaid eligibility standards through 2014 as part of the maintenance of effort provision. The purpose of this effort is to stop states from limiting eligibility until the federal government reimbursement increases take effect in 2014.

The Supreme Court’s June 28th ruling on Medicaid expansion caused many leaders to call into question the ACA’s maintenance of effort provision. The CRS report confirms that the ruling does not free governors to modify current Medicaid eligibility rules. The Obama administration has made similar arguments in letters to governors, saying that the Supreme Court ruling only affected Medicaid expansion and did not carry over into other provisions such as maintenance of effort.

The CRS report was less clear regarding whether states can choose to expand Medicaid after 2014. The report said that Health and Human Services Secretary Kathleen Sebelius could decide  that states must join the expansion by 2014, noting, however that a state could argue that if it meets the health care law’s Medicaid requirements at a later date, the federal government must support them. The report also said that it is unclear if states can choose to cover some, but not all, of the newly eligible group of Medicaid beneficiaries.

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The Centers for Medicare and Medicaid Services (CMS) issued a bulletin and question-and-answer explaining hospital presumptive eligibility. The documents are intended to aid hospitals in determining individual eligibility for Medicaid, or presumptive eligibility, under the Affordable Care Act (ACA). The documents provide relevant information on eligible populations, entities that can make coverage determinations, qualification standards, and federal matching assistance that may be relevant for hospitals that may treat patients without insurance. All states are expected to include an amendment to their Medicaid State Plans implementing the new presumptive eligibility standards.
The Centers for Medicare and Medicaid Services (CMS) issued a new report chronicling the numbed of individuals deemed eligible for Medicaid or the Children's Health Insurance Program (CHIP) during the first three months of open enrollment. The report stated that 6.3 million Americans enrolled in Medicaid or CHIP in state-based Marketplaces or in-person at state Medicaid offices. The report does not, however, provide numbers for Medicaid enrollment in federally-facilitated Marketplaces, nor does it differentiate between individuals that are newly eligible for Medicaid as a result of expansion and those that were previously eligible under the original Medicaid criteria.
In a final rule released today, the Centers for Medicare and Medicaid Services (CMS) addressed several issues in implementing the Affordable Care Act (ACA), including subsidy eligibility. Below are key highlights from the 606-page rule:
  • The rule provided additional information regarding the administration's decision to delay the employer shared responsibility requirement. In order to determine if an individual is eligible for federal subsidies, the Exchange must be aware as to whether or not the individual has access to affordable health insurance from his or her employer. As a result of the delay, the Exchange will have no comprehensive database or official records reporting if an individual has access to affordable coverage, and thereby determine subsidy eligibility. The Exchange will therefore rely upon applicant self-reported information, verification against other information sources such as tax returns, and sampling of a group of applicants in which the Exchange will manually call the applicant's employer.
  • Individuals who are deemed eligible for a subsidy based upon their applications will receive subsidies during the time in which their eligibility review is being conducted. The audit period is reported to last for 90 days.
  • CMS outlined how the Exchange should coordinate with state Medicaid and CHIP officials to determine who is eligible for these programs.
  • The rule also describes key provisions of the Alternative Benefits Plan, Medicaid's benchmark plan for states that expanded Medicaid. In addition, the rule updates the cost-sharing and premium regulations for Medicaid plans. Specifically, states are now permitted to charge higher cost-sharing for prescription drugs and non-urgent visits to the emergency room.
  • CMS clarified that cost-sharing of plans offered on the Exchange must be considered in determining whether or not it would be cost effective to offer this plan to Medicaid beneficiaries through the premium assistance model.
A provision in the Affordable Care Act (ACA) incentivized state Medicaid agencies to design and develop new eligibility systems by offering a 90% federal reimbursement for the associated costs. A set of FAQ released by the Centers for Medicare and Medicaid Services (CMS) explains that state Medicaid programs will be eligible for an increased federal match rate of 75% for using and maintaining these upgraded eligibility system by January 1st, 2014. To qualify for the enhanced rate for the upgraded systems, states must meet operation and maintenance standards in the following categories:
  • personnel costs
  • forms
  • software maintenance
  • data entry
  • computer operators
  • coding clerks
States that choose not to expand their Medicaid program under the ACA will still be eligible for the increased reimbursement if they meet the specified upgrade requirements. In addition to these stipulations, the FAQ also stated they would not authorize 1115 demonstration waivers that placed enrollment caps or periods of ineligibility for the new Medicaid-eligible adult groups under the ACA.  
The U.S. Department of Health and Human Services (HHS) today released a proposed rule addressing essential health benefits and eligibility notices and the appeals process for Medicaid and exchange eligibility. The Centers for Medicare & Medicaid Services (CMS) also released a summary of the lengthy rule. HHS said the proposed rule would give states more flexibility when operating their Medicaid programs and sheds light on how consumers will receive coordinated communications on eligibility determinations and how they can submit appeals. The rule would also allow states to increase cost-sharing for beneficiaries, including for non-preferred drugs and the non-emergency visits to emergency rooms. The rule is set for publication in the January 22 Federal Register. Comments are due by February 13.
The Department of Health and Human Service’s (HHS's) Centers for Medicare & Medicaid Services (CMS) today announced new guidance to help states as they begin to plan converting current net income eligibility thresholds to equivalent modified adjusted gross income (MAGI) thresholds in the Medicaid program and Children's Health Insurance Program (CHIP). The CMS publication describes the conversion methodology and the timeframe for executing the conversions.
Republican governors sent a letter to President Barack Obama on July 10 requesting that he clarify a number of issues regarding the U.S. Supreme Court's June 28 decision to uphold the Affordable Care Act (ACA). In response...
The interaction between Medicaid and Exchanges around eligibility determination issues represents one of the most important and complex aspects of the ACA. An estimated 28 million adults, along with 19 million children, can be expected to transition at least once annually between insurance affordability programs, as Medicaid and premium subsidies are termed under implementing CMS regulations. Collaboration between Medicaid agencies and Exchanges is essential in order to avert unnecessary delays in eligibility determinations and breaks in coverage that in turn can affect not only the affordability of care but access itself, given the link between coverage and health care access through plans’ provider networks...
The Affordable Care Act (ACA), in addition to expanding coverage to individuals with incomes below 133 percent of the federal poverty level (FPL), includes provisions designed to preserve existing Medicaid coverage -- known as the maintenance of effort provision, or MOE -- until the ACA is fully implemented. The ACA’s MOE provision requires states to maintain their current Medicaid eligibility standards, methodologies, and procedures until the Secretary of the Department of Health and Human Services (HHS) determines that a state Exchange is fully operational. For children, the ACA’s MOE extends through September 30, 2019. States may reduce eligibly for certain non-pregnant, non-adult...
The State Health Reform Assistance Network, in conjunction with the National Academy of State Health Policy and the Robert Wood Johnson Foundation, released a checklist detailing Medicaid requirements that each state must meet by 2014, irrespective of whether or not a state expands Medicaid eligibility as described in the Affordable Care Act (ACA). To accompany the outlined requirements and optional provisions detailed in the report, State Health Reform Assistance Network has also included a resource list with tools and analyses that can be incorporated to aid in Medicaid requirement implementation. The checklist is divided into five categories that should be altered in response to pending Medicaid changes, each of which containing various requirements to satisfy the specified category:
  • Eligibility and Enrollment
  • Medicaid Operations
  • Medicaid Financing
  • Medicaid Benefits
  • Consumer Assistance