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Frequently Asked Questions

Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.

Showing 41 to 50 of 54 results

How will Essential Health Benefits (EHB) be defined for Medicaid benchmark or benchmark-equivalent plans?

Since 2006, State Medicaid programs have had the option to provide certain groups of Medicaid enrollees with an alternative benefit package known as "benchmark" or "benchmark-equivalent" coverage, based on one of three commercial insurance products or a fourth, "Secretary-approved" coverage option. Beginning on January 1, 2014, all Medicaid benchmark and benchmark-equivalent plans must include at least the ten statutory categories of Essential Health Benefits. Under the Affordable Care Act, the medical assistance provided to the expansion population of adults who become newly eligible for Medicaid as of January 1, 2014, must be provided consistent with section 1937 benchmark authority.

For Medicaid alternative benefit plans, three of the benchmark plans described in section 1937 (the State's largest non-Medicaid HMO, the State's employee health plan, and the FEHBP BCBS plan) may be designated by the Secretary as EHB benchmark reference plans, as described in the EHB Bulletin (link below). A State Medicaid Agency could select any of these section 1937 benchmark plans as its EHB benchmark reference plan for Medicaid. There would be no default EHB benchmark reference plan for purposes of Medicaid; each State Medicaid Agency would be required to identify an EHB benchmark reference plan for purposes of Medicaid as part of its 2014-related Medicaid State Plan changes.

If the EHB benchmark reference plan selected for Medicaid were to lack coverage within one or more of the ten statutorily-required categories of benefits, the section 1937 alternative benefit plan would need to be supplemented to ensure that it provides coverage in each of the ten statutory benefit categories. This would be in addition to any other requirements for Section 1937 plan, including Mental Health Parity and Addition Equity Act compliance.

For more information about the Essential Health Benefits, please see CCIIO's bulletin from December 2011 (available at http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf ) and the CMCS informational bulletin from February 2012 (available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-02-17-12.pdf (PDF, 71.68 KB).

FAQ ID:93036

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Could a State select a different Essential Health Benefits (EHB) benchmark reference plan for its Medicaid section 1937 alternative benefit plans than the EHB reference plan it selects for the individual and small group market?

Yes. A State is not required to select the same EHB benchmark reference plan for Medicaid section 1937 plans that it selects for the individual and small group market, and it could have more than one EHB benchmark reference plan for Medicaid (for example, if the State were to develop more than one benefit plan under section 1937).

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FAQ ID:93041

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Could a State select its regular Medicaid benefit plan as its section 1937 alternate benefit plan for the new adult eligibility group?

Yes. A State could propose its traditional Medicaid benefit package as a section 1937 alternate benefit plan under the Secretary-approved option available under section 1937 of the Social Security Act. The State would have to ensure that the ten statutory categories of EHB are covered, either through that benefit plan or as a supplement to that plan.

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FAQ ID:93046

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How do the managed care rules at 42 CFR 438 apply to benchmark benefit plans?

The managed care regulations apply to all benefits delivered through a managed care delivery system, regardless of the authority under which the benefits are provided or enrollment is required. Thus, any State which uses a managed care organization to deliver benefits under the authority of section 1937 of the Act must comply with the managed care regulations at 42 CFR 438.

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FAQ ID:93051

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Will 1915(c) waivers continue in the future?

Yes. 1915 (c) waivers are optional programs that most States currently operate and can continue to operate. States interested in making changes to their 1915(c) waivers should contact their CMS Regional Office with specific questions.

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FAQ ID:93056

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Which eligibility groups were consolidated under the March 2012 eligibility final rule?

The Medicaid eligibility final rule at 435.110, 435.116 and 435.118 set forth the mechanism for consolidating certain federal eligibility categories into four main groupings: adults, children, pregnant women and parents/caretaker relatives. The table provided below lays out the consolidation of mandatory and optional eligibility groups (a version of this table was also included as part of the preamble to the proposed rule).

Realignment of Medicaid Eligibility Groups

Before After Affordable Care Act Final Rule
Mandatory Medicaid Eligibility Groups (Pre-Affordable Care Act)

Parents/Caretaker Relatives

(section 435.110)

Pregnant Women

(section 435.116)

Children <19

(section 435.118)

Low-Income Families - 1902(a)(10)(A)(i)(I) and 1931 Former AFDC - 435.110 x x x

Qualified Pregnant Women & Children<19 -1902="" a="" 10="" a="" i="" iii="" -="" 435="" 116="" p="">

x x
Poverty-Level Related Pregnant Women & Infants - 1902(a)(10)(A)(i)(IV) - No rule x x
Poverty-Level Related Children Ages 1-5 - 1902(a)(10)(A)(i)(VI) - No rule x
Poverty-Level Related Children Ages 6-18 - 1902(a)(10)(A)(i)(VII) - No rule x

Optional Medicaid Eligibility Groups (Pre-Affordable Care Act)

Parents/Caretaker Relatives

(435.110)

Pregnant Women

(435.116)

Children <19

(435.118)

Families & Children Financially Eligible for AFDC - 1902(a)(10)(A)(ii)(I) - 435.210 x
Families & children Who Would be Eligible for AFDC if Not Institutionalized - 1902(a)(10)(A)(ii)(IV) - 435.211 x x
Poverty-Level Related Pregnant Women & Infants - 1902(a)(10)(A)(ii)(IX) - No rule x x

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FAQ ID:93131

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Do States need to track people enrolled in the adult group who become pregnant?

States are not required to track the pregnant status of women enrolled through the new adult group. Women who enroll in the adult group who later become pregnant will have the option of either staying enrolled in the adult group, or requesting that the State move them to a pregnancy-related eligibility group. This is most likely to occur if women need specific benefits that are not available under the adult group benchmark benefit package.

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FAQ ID:93136

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If a woman indicates on the application she is pregnant, do States need to enroll her as a pregnant woman if she is otherwise eligible for the adult group? Would there be a need to track pregnancy if the benefits for both groups are the same?

If a woman indicates on the application that she is pregnant, she should be enrolled in Medicaid coverage as a pregnant woman. The Affordable Care Act specifies that pregnant women are not eligible for the new adult group. As mentioned above, if a woman enrolled in the adult group later becomes pregnant, she will have the option to stay enrolled in the adult group or request that the State move her to a pregnancy-related eligibility group.

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FAQ ID:93141

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In 2014, will the eligibility groups for people with breast and cervical cancer and disabled workers continue to exist?

Yes, the breast and cervical cancer group and the eligibility group for working disabled individuals will remain optional eligibility groups which States may elect. The Affordable Care Act did not alter the financial or non-financial requirements or methodologies used to determine eligibility for these groups, both of which are exempt from the application of Modified Adjusted Gross Income (MAGI) methodology for determining income.

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FAQ ID:93151

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In 2014, what happens to existing groups like section 1931 and Transitional Medical Assistance (TMA)?

Coverage under section 1931 of the Act was not repealed with the ACA and will remain in effect in 2014. As noted in the table above, eligibility for parents and caretaker relatives under section 1931 is implemented at section 435.110 of the regulations; eligibility for pregnant women under section 1931 is implemented at section 435.116 and eligibility for children at section 435.118. TMA under section 1925 of the Act will sunset on December 31, 2012, unless extended by Congress. If Congress elects to extend section 1925 of the Act beyond December 31, 2013, States will need to provide TMA to eligible individuals as set forth in their approved State plans. Note that the 4-month extension for individuals losing eligibility under section 1931 of the Act due to increased earnings or hours of work (see sections 1902(e)(1)(A) and 1931(c)(2) of the Act), and the 4-month extension of eligibility for individuals losing eligibility due to increased spousal support (see section 1931(c)(1) of the Act) do not have a sunset date and would therefore still apply in 2014 unless repealed by Congress. The extension of eligibility for individuals losing coverage under section 1931 due to increased child support will no longer be relevant in 2014, as child support is not counted as income under MAGI-based methodologies.

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FAQ ID:93156

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