Questions and Answers from the September 28, 2011, Webinar: “Choices for States in the Newest Federal Eligibility and Enrollment Regulations”

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September 2011

The following questions were submitted during Enroll America’s webinar held on September 28, 2011. Enroll America has provided answers to as many questions as possible. Note, some questions were asked multiple times, so we have combined or synthesized questions in many cases. We encourage you to submit your questions about the August eligibility and enrollment regulations to

Medicaid Eligibility

Q: Will asset tests be eliminated for all Medicaid categories on January 1, 2014?

A: For most Medicaid eligibility categories, asset tests will no longer be permitted beginning on January 1, 2014. Some groups (those who are eligible for Medicare, people in the Medicaid medically needy category, people with disabilities, and those who are eligible for Medicaid because of their eligibility for another program) will maintain their current income-counting rules.

Q: Will individuals who previously did not qualify for Medicaid because of assets be eligible in 2014? If so, are they considered “newly eligible” and eligible for a higher federal matching rate?

A: As of January 1, 2014, assets are no longer part of the eligibility determination for most people in Medicaid (primarily those who are not elderly and who do not have a disability), and they will not count against someone who is otherwise eligible.

CMS has not yet issued final regulations to states about how to determine who is “newly eligible” for the purposes of federal matching rates. However, CMS staff have indicated that they are likely to establish a system that will rely on sampling or data to determine a state’s matching rate rather than tying the federal match rate to individual’s eligibility. CMS is seeking input on this issue in comments to the August 2011 proposed regulations.

Q: What protections will be in place to ensure that states gather the appropriate information to determine whether an applicant is eligible for Medicaid based on disability, and to ensure that those individuals are enrolled in the appropriate category?

A: States will need to screen for income-based eligibility first, whether an individual applies through the Medicaid agency or the exchange. The proposed federal regulations suggest that the state (either the Medicaid agency or the exchange, depending on which agency gets the application) should screen the individual for potential Medicaid eligibility on other bases (including disability) and prompt the individual to request a Medicaid eligibility determination on these bases. The regulations do not identify the specific questions that must be included in the application for this kind of screening.

Q: If an individual is eligible for Medicaid pending verification, can the individual receive services and have those services billed to and paid by Medicaid? If so, and the person is later found to be ineligible or doesn’t turn in the documentation within the 90 day period, will the state recoup the payment from the individual or the provider?

A: Income-based Medicaid eligibility determinations should be occurring in real time for most applicants by 2014. Individuals with income greater than the applicable Medicaid eligibility level in the state will be eligible to receive a premium tax credit and enroll in exchange coverage while their Medicaid application is pending, and they will not be liable to repay these advance payments if they are ultimately found to be eligible for Medicaid. The proposed regulations do not specify how claims will be handled in cases where an individual fails to complete the required verification documentation and is not ultimately determined to be eligible.

Q: Will Medicaid retroactivity (for unpaid medical bills that were incurred up to three months prior to the month of application) still apply after January 1, 2014?

A: Yes, if an individual was previously uninsured and has unpaid medical bills.

12-Month Eligibility/Renewal

Q: Will federal regulations take precedence over state law? For example, some states currently require Medicaid recipients to report their income every six months. Will the new rules override such a requirement?

A: This is unclear based on the proposed regulations, which state that Medicaid and CHIP eligibility must be redetermined every 12 months. This is a change from existing regulations, which require that redeterminations occur “at least every 12 months.” Enroll America is requesting clarification of CMS’s intentions in our comments on the proposed regulation, which are available on our website. However, shifting to annual redeterminations in Medicaid and CHIP would encourage alignment across Medicaid, CHIP, the Basic Health Plan, and exchange coverage.

Q: Please define “renewal.” Does 12-month renewal mean guaranteed eligibility for 12 months?

A: The proposed federal rules do not call for 12-month continuous eligibility (in which an individual remains covered for 12 months regardless of changes in income that may happen during that time). Technically, as is done today in Medicaid, individuals in Medicaid, CHIP, the Basic Health Plan, or exchange coverage will be required to report changes in circumstance that may affect eligibility. One interpretation of the proposed regulations is that, if an individual’s circumstances do not change, renewal should take place only once a year (but as mentioned in the previous question, Enroll America is requesting clarification about this provision).

Q: Will states ask enrollees if they still want coverage at renewal time when using automatic electronic enrollment?

A: The proposed rules suggest that renewals will be based on the information that is available in existing databases as much as possible, but that individuals will be given an opportunity to correct any information obtained from such databases and provide any additional information needed in order to renew coverage for another 12-month period. People will be able to renew online, by phone, or through the mail.

Changes in Circumstances

Q: How will using MAGI (modified adjusted gross income), which is based on the prior year’s income, work, given that low- and middle-income households experience frequent fluctuations in income throughout the year?

A: Individuals will be given an opportunity to affirm or correct information about their income at the time of application, and they will have the opportunity to report changes in income throughout the year. This is a particularly challenging part of the proposed regulations, given the differences in income definitions for Medicaid (currently, monthly income) and exchange coverage (projected annual income). Enroll America is requesting clarification on this part of the regulation.

Q: Must people who receive a premium tax credit report every change that could affect tax credit amounts? If so, that seems problematic. For example, a few more hours at work during a week would mean a higher income, hence a smaller credit.

A: The proposed regulations solicit comments on whether exchanges should be required or allowed to limit reporting requirements to changes of a certain magnitude (for example, changes greater than a certain threshold: 5, 10, or 15 percent of income; or changes that would significantly alter an individual’s or household’s eligibility). Exchanges will need to find the appropriate balance so that enrollees are not confused by the reporting requirements (or deterred from enrolling because of them), but also so that individuals have the opportunity to report changes in income that could affect how much they need to repay at the end of the year if they receive a larger credit than they are ultimately qualified to receive.

Q: If a client’s family composition or income varies over the course of a year and the client is required to report any changes, his or her eligibility status may also change. How will this be managed if clients need to change their coverage but there are limited enrollment periods?

A: The proposed rule requires enrollees in Medicaid, CHIP, Basic Health, or an exchange to report changes in circumstance—including changes in incarceration status, residency, immigration status, household income or household size, availability of employer-based coverage, or income—that may affect eligibility. If an individual is not enrolled in exchange coverage but experiences a change in circumstance that may make him or her newly eligible, the person will have the opportunity to enroll outside the annual open enrollment.

Q: What about kids whose divorced parents alternate claiming the child on their federal tax forms under the Earned Income Tax Credit (EITC)? Will the child’s parents have to re-apply each year as the child’s dependency status fluctuates?

A: The proposed regulations are not definitive on this issue.

Data Matching

Q: What is the federal data hub?

A: The proposed regulations (Section 435.949) mention that the Secretary of Health and Human Services (HHS) will establish an electronic service that states must use to verify certain eligibility information. This service, which has been dubbed the “federal data hub,” will contain information from sources including, but not limited to, the Social Security Administration, the Department of Treasury, and the Department of Homeland Security, as well as other federal offices that may have information relevant to health coverage eligibility,

Q: Will the verification be automatic? If so, who determines which data sources are used? Will all the exchanges use the same type of verification?

A: Although states must use the federal data hub to verify relevant information, states also have the option to use alternative mechanisms to collect and verify information, subject to the HHS Secretary’s approval. States also have the flexibility to accept self-attestation of many eligibility elements, including income, residency, age, and date of birth. Self-attestation must be accepted for household composition and pregnancy. The goal is for verification to be electronic and in real time, so, in this sense, it will be automatic.

Q: Can someone initiate an application by providing identifying data (e.g., name, date of birth, Social Security number, and address) and authorize the state to obtain other data that are relevant to eligibility? Under this approach, the consumer would be presented with a pre-populated form showing income, as demonstrated by available data. As happens with Medicaid renewals, the consumer would change and confirm information on the pre-populated form.

A: The regulations do not provide an answer to this question. However, Enroll America would support such an arrangement, which could significantly reduce the administrative burden on individuals seeking coverage and ensure that more individuals are successfully enrolled.

Coordination across Programs

Q: Suppose an exchange finds someone eligible for Medicaid. Will the consumer be able to select a plan using the exchange website Or will the consumer be referred to Medicaid for further processing? More broadly, are there any circumstances under which a consumer will need to be referred from the exchange to the Medicaid agency to complete the eligibility determination and enrollment process?

A: In most cases, ideally, consumers should be able to complete the entire enrollment process in real time at the same place whether they and their family members are found eligible for Medicaid, CHIP, a premium credit, or unsubsidized coverage that is available through an exchange. The HHS Secretary will be issuing a template application that any state can use. Any application a state wishes to use other than the Secretary’s model must be approved by the Secretary. However, the federal rules do seem to allow states discretion regarding how to handle the “hand-off” between the exchange and Medicaid, even if the consumer is found eligible for an income-based Medicaid group. The federal rules to do not appear to require the exchanges to make Medicaid eligibility decisions that go beyond the income-based eligibility groups. Therefore, state Medicaid agencies will be responsible for ensuring that those applicants who may be eligible for another Medicaid group (e.g., if the person has a disability or is over age 65) get enrolled in the correct category of Medicaid, since this has implications for the benefits packages that are available to an individual and for federal financial participation. If a state chooses to have its Medicaid agency handle all exchange eligibility determinations, this process may be easier to streamline.

Q: Have the states been receptive to using MAGI? Have there been any proposals to use this requirement across all entitlement programs to simplify eligibility across the board (e.g., for TANF and SNAP [food stamps])?

A: Requiring the use of MAGI methodologies across other need-based programs would require federal legislative changes, but the federal government and states are exploring ways to streamline eligibility across these programs (sometimes called “horizontal integration”). Expect much more information on this topic to come out in the next couple of years.


Q: Can you further explain the navigator role? What will the licensing requirements be for navigator organizations? Does the organization need to be certified, or do individual associates of the organizations need to be certified?

A: The proposed exchange rules, which were published in July of this year, go into greater detail about navigator program requirements. Exchanges must establish navigator programs through which they award grants to eligible public or private entities to perform a number of eligibility and enrollment-related functions. These functions include conducting public education activities to raise awareness about the exchange; providing information and assistance in a fair, accurate, and impartial manner; facilitating enrollment in the coverage that is available through the exchange; providing referrals to other sources of consumer assistance; and
providing information that is culturally and linguistically appropriate for the population that is served by the exchange (including in a manner that is accessible for people with disabilities).

The proposed regulations require navigators to meet any licensing or certification requirements that a state or exchange may prescribe, but the regulations do not propose specific licensing requirements. In our comments on these proposed rules (available on our website), Enroll America requests more detail as to how navigator programs will work.

Assorted Exchange Issues

Q: As a payer who would be a Qualified Health Plan (a plan offered through an exchange), will we need to be able to interface with the exchange in real time?

A: The proposed eligibility and enrollment regulations to not provide an answer to this question.

Q: What is the process if the exchange identifies possible fraud?

A: The current proposed regulations do not explicitly address waste, fraud, and abuse prevention standards, but future regulations or guidance will. If an individual is receiving a premium tax credit and is found at the time of reconciliation not to have been eligible for the tax credit, the individual will be responsible for repaying any undue premium tax credit amounts received (with certain limits for low-income people).

Q: What about applicants that don’t file tax returns? How will their eligibility be determined?

A: An individual must be an “applicable taxpayer” in order to be eligible for a premium tax credit in the exchange. When tax return data are unavailable for an applicable taxpayer who is applying for coverage, the exchange must attempt to verify the applicant’s attestation of income based on other electronic data sources that HHS has approved (to be determined). If electronic data are not available or do not support the applicant’s attestation, the exchange must give the applicant 90 days to present satisfactory evidence documenting his or her income (or resolving any inconsistencies with existing databases). Proposed Medicaid rules suggest that if an individual does not file a tax return (and is not claimed as a tax dependent by another taxpayer), the household consists of the individual and those individuals living in the same residence, including a spouse (if applicable, and if living with the individual), children under age 19 (or under age 21 if full-time students), and, if the individual is under age 19, any parents or siblings living with the individual.

Q: How much time will state exchanges have to determine eligibility in the exchange?

A: Per the proposed rules, exchanges should determine eligibility within a reasonable amount of time, and the rule encourages adoption of real-time verifications as soon as the technology permits.

Federally Operated Exchange

Q: If a state does not set up its own exchange, residents of the state will be able to participate in a federally operated exchange. What will states need to do to support the federally run exchange? What penalty will a state incur if it fails to provide the necessary support to a federally run exchange?

A: Regulations have not yet been issued on federally operated exchanges.

Q: When will CMS publish their requirements for federally run exchanges?

A: It is unclear when or whether HHS will be issuing additional guidance on federally run exchanges.

Regulations/Federal Process

Q: When does CMS anticipate issuing final Medicaid eligibility regulations?

A: Comments on the proposed rule are due by October 31, 2011. The final rule will be issued after that, but no date has been set.

Q: A lot of these changes are dependent on technology. What is the federal government doing to try to help states identify technology that will help implement these streamlined processes?

A: The federal government is offering a variety of implementation grants (exchange planning grants last year, and establishment grants this year) and an enhanced Medicaid matching rate for states to invest in improved technology. Last year, the federal government also awarded seven “innovator grants” to Kansas, Maryland, Oklahoma, Oregon, New York, Wisconsin, and a consortium of New England states to help these states design and implement the information technology infrastructure that will be needed to support state exchanges. (Subsequently, Kansas and Oklahoma returned their innovator state grants to the federal government.) These states will develop models that can be adopted and tailored by other states.

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