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.
Frequently Asked Questions
How does Medicaid Eligibility Quality Control (MEQC) differ from Payment Error Rate Measurement (PERM)?
The MEQC requirements on active case reviews generally mirror the requirements of the eligibility component of PERM reviews. The regulation requires that states perform reviews of a sample of active Medicaid and Children’s Health Insurance Program (CHIP) cases to identify new eligibility approvals and renewals that were made in error. As in PERM, states will be required to submit case-level reports on the sampled cases they review and corrective action plans that describe steps taken to remediate the errors found.
However, in contrast to PERM, when states identify errors in their active Medicaid and CHIP cases, they will be required to undertake a payment review. This will consist of a review of all claims paid over the first three months after an erroneous eligibility determination was made, and a summary of the overstated or understated liability. States will in turn be required to submit adjustments to the amount of federal financial participation (FFP) claimed through the CMS-64 reporting process for Medicaid and the CMS-21 reporting process for CHIP. The adjustments are required for identified claims in which too much or too little FFP was received. There is no payment review or re-crediting requirement in PERM, although disallowance of FFP can be taken in states whose PERM error rate exceeds the national threshold of 3% based on a formula described at 42 CFR 431.1010. MEQC contains no such disallowance provision.
The MEQC program also contains one other significant element that is not found in PERM. Besides the requirement that states review at least 400 cases in their active case universe (including a minimum of 200 cases), MEQC requires states to review at least 400 negative case actions. At least 200 of these must be Medicaid and 200 must be CHIP. Negative case actions involve erroneous denials of Medicaid or CHIP eligibility or erroneous terminations from Medicaid or CHIP. This is an area with no PERM counterpart in which states will be developing case-level reporting and corrective actions. Negative case action reviews will not be triggered by PERM findings. Largely for this reason, the regulation requires that states pull their sample of these from the entire Medicaid and CHIP universe of cases. By sampling from the full range of Medicaid and CHIP cases, states should be able to obtain an overview of those sectors in their programs that may be especially vulnerable to improper denials or terminations.
FAQ ID:93196
SHARE URLIs there a simplified Payment Error Rate Measurement (PERM)/Medicaid Eligibility Quality Control (MEQC) timeline with milestone dates/cycles that can be provided to states (all cycles)?
The PERM/MEQC dates/cycles are as follows:
PERM Cycle* | PERM Review Period | MEQC Planning Document Due to CMS | MEQC Review Period | MEQC Case-Level Report on Findings and CAP Due to CMS |
---|---|---|---|---|
Cycle 1 | July 1, 2017 – June 30, 2018 | November 1, 2018 | January 1 – December 1, 2019 | August 1, 2020 |
Cycle 2 | July 1, 2018 – June 30, 2019 | November 1, 2019 | January 1 – December 1, 2020 | August 1, 2021 |
Cycle 3 | July 1, 2019 – June 30, 2020 | November 1, 2020 | January 1 – December 1, 2021 | August 1, 2022 |
*??
CMS = Centers for Medicare & Medicaid Services
CAP = ??
FAQ ID:95156
SHARE URLOur state included dental services along with physician (non-dental) services in our state's Upper Payment Limit (UPL) demonstration of the practitioner Average Commercial Rate (ACR) using the Medicare Equivalent of the ACR. Should we keep both services together in one demonstration or should we separate the services out for two different ACR demonstrations?
Dental services are not covered under Medicare, which means the state may not compare Medicaid rates for comparable dental services for the Medicare Equivalent of the ACR. The state may calculate a dental ACR in order to make supplemental payments to dental services providers and continue to calculate the Medicare Equivalent of the ACR for other services covered by Medicare. The state should submit two separate ACR demonstrations, one for dental services and one for physician (non-dental) services. This will involve completing two versions of the Office of Management and Budget-approved template. If the same provider provides both physician and dental services the state would differentiate the provider information between the two demonstrations by appending the Medicare Certification Number (Medicare ID) (variable 112) with a letter, such as an -A or a -B. For example, if the Medicare ID was 123456, it would be depicted in the physician ACR as 123456-A and in the dental ACR as 12345-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number.
FAQ ID:92441
SHARE URLHow will a state determine a child's household composition when the child leaves the home of his/her parent(s) to live with a caretaker relative, but is still expected to be claimed as a tax dependent by one or both parents.
CMS regulations at 42 CFR 435.603(f)(2) provide that the parents would be included in the child's household in this situation. However, if the parents do not intend to continue to claim the child as a tax dependent for the following tax year, states may alternatively use the option provided at 435.603(h)(3) to consider the child's move to the live with another caretaker relative as a "reasonably predictable change in income" and apply the non-filer rules to the child at 435.603(f)(3). Under the non-filer rules, neither the parents nor the caretaker with whom the child is living would be included in the child's household for purposes of Medicaid and CHIP eligibility.
Note that to be claimed as a "qualifying child," children generally must live with their parents for at least half of the year (certain exceptions apply), but parents may also be able to continue to claim a child as a "qualifying relative." States are not expected to determine whether or not a parent is permitted to claim their child as a tax dependent or not, but states may wish to consult IRS Publication 501 to better understand the general requirements which must be met for a tax filer to claim another individual either as a "qualifying child" or "qualifying relative." IRS Publication 501 can be accessed at the following link: http://www.irs.gov/pub/irs-pdf/p501.pdf.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92571
SHARE URLIs there a difference between the definition of Indian/Native American for Medicaid and the Exchange. Can you clarify what the difference is?
For purposes of eligibility for coverage through the Marketplace, the Affordable Care Act defines Indians as individuals who are members of a federally recognized Indian Tribe. The definition of Indian currently in use for Medicaid beneficiaries follows a broader definition that includes descendants of Indians and all American Indians and Alaska Natives. As a result, American Indians and Alaska Natives who are not members of an Indian tribe would not be eligible for exemptions available through an Exchange, including from individual responsibility payments, qualification for special monthly enrollment periods and cost-sharing reductions.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92576
SHARE URLWhat are some examples of income that is not considered taxable, and therefore excluded from MAGI?
Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), Veterans' disability, Workers' Compensation, child support, federal tax credits, and cash assistance are common types of income that are not taxable. Please see Question 5 below for additional details on veterans' benefits.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92581
SHARE URLWill Veterans Administration (VA) benefits be counted as taxable income effective January 1, 2014?
The IRS has provided guidance on how VA benefits should be considered when calculating income. As noted in IRS Publication 17, states should not count any veterans benefits paid under any law, regulation or administrative practice administered by the Department of Veterans Affairs in their income calculations. CMS agrees that VA benefits are not part of the Modified Adjusted Gross Income (MAGI) calculation.
Following are some examples of payments issued to veterans' or their families that are not taxable:
- Education, training and subsistence allowances
- Disability compensation and pensions payments for disabilities paid either to veterans or their families
- Grants for homes designed for wheelchair living
- Grants for motor vehicles for veterans who lost their sight or the use of their limbs
- Veterans' insurance proceeds and dividend paid either to veterans or their beneficiaries, including the proceeds of a veteran's endowment policy paid before death
- Interest on insurance dividends left on deposit with the VA
- Benefits under a dependent care assistance program
- The death gratuity paid to a survivor of a member of the Armed Forces who died after September 10, 2001
- Payments made under the compensated work therapy program
- Any bonus payment by a state or political subdivision because of service in a combat zone
Additional information on how the IRS views veteran's income can be found at http://www.irs.gov/pub/irs-pdf/p17.pdf.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92586
SHARE URLHow should states handle eligibility renewals between January 1, 2014 and March 31, 2014 in order to comply with the ACA provisions that prohibit states from terminating an individual's existing Medicaid eligibility prior to April 1, 2014.
According to section 1902(e)(14)(D)(v) of the Act, implemented at 42 CFR 435.603(a)(3), a person enrolled in Medicaid on or before December 31, 2013, shall not be found ineligible solely because of the application of MAGI and new household composition rules before March 31, 2014, or the individual's next regular renewal date, whichever is later.
States have two options regarding implementation. They can apply both pre-MAGI rules and MAGI rules to anyone whose renewal date falls between January 1 and March 31, 2014 as described below. Alternately, states may request the waiver authority to delay renewals outlined in our May 17, 2013 guidance titled, "Facilitating Medicaid and CHIP Enrollment and Renewal in 2014" (available at http://medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO-13-003.pdf).
The steps described below will ensure that Medicaid enrollees who come up for renewal between January and March 2014 are addressed appropriately. For example, for an individual who comes up for renewal on February 1, 2014, states need to:
- Conduct an eligibility redetermination by applying MAGI-based methods (at the converted income standard). If eligible, renew coverage for a 12-month period ending in February 2015.
- If the individual is found to be ineligible under step 1, determine whether s/he remains eligible based on 2013 (current) methods and income standard. If so, a finding of eligibility until April 1, 2014 is necessary under the 2013 methods. Go to step 4.
- If the individual is not eligible per either step 1 or 2, consider whether the individual might be eligible on other bases of eligibility, and pursue any possibilities. If no other pathways apply, provide the individual with notice of termination and appeal rights and transfer their account to the Exchange (or CHIP) for eligibility determination and enrollment in a QHP (or CHIP).
- On April 1, 2014, for those who remain eligible per step 2 (using 2013 methods and income standards), consider whether the individual qualifies on other bases of eligibility. If the individual does, renew eligibility until April 1, 2015. If not, provide notice and appeal rights for termination effective April 1, 2014.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92596
SHARE URLWhich 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 |
Supplemental Links:
FAQ ID:93131
SHARE URLDo 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.
Supplemental Links:
FAQ ID:93136
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