Frequently Asked Questions

No, overall the new methodology does not change the number of people eligible for Medicaid. The MAGI-based standard will result in approximately the same number of people being eligible under the new standard as would have been eligible under the old standard. However, there may be some differences in which people will qualify--or not qualify--depending on how they might have fared under the old system (with deductions and disregards).

FAQ ID:92481

Before MAGI, if a state's income limit was 100% of the FPL--the state would first look at the person's gross income, then subtract out (for example) 30% of their earned income and an amount they spend on childcare as work-related expense deductions and then compare that net income to 100% of the FPL. This means that under the pre-MAGI rules, in a state with an income eligibility limit of 100% of the FPL, a person with income over 100% of the FPL can qualify for Medicaid (because of the deductions and disregards).

FAQ ID:92486

The state will look at the individual's modified adjusted gross income, deduct 5%, which the law provides as a standard disregard, and compare that income to the new standard.

FAQ ID:92491

Based on guidance issued in December 2012 (PDF, 177.59 KB), CMS worked with states to set their new standards. Most states used a model that determines the average value of the disregards a state had in place and then added that amount to the old standard to create the new eligibility levels. In the example above, in a state with a net income standard of 100% of the FPL, if the average value of the disregards equaled 6 percentage points of the FPL, that value would be added to the old standard for a new eligibility standard of 106% of the FPL.

FAQ ID:92496

No. A disability determination is not directly related to the eligibility determination, even though the outcome of that determination may be used to identify the appropriate eligibility group, financial methodology and the benefits that will be available to the individual. The eligibility group, financial methodology and benefits are based on the state plan, not on the eligibility system. Although the disability determination itself is not eligible for the 75% match, the entry of the disability information into the eligibility system may be matched at 75%. This analysis is based on the SMM Sec. 11276.7 B, which discusses prior authorization and claims processing. The prior authorization itself is not eligible for the 75% match, however the program decision, based on that prior authorization, to pay or not pay a claim that is pending in the system is eligible for the 75% match.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92651

Individuals who assist applicants by facilitating their applications, who perform outreach activities, or who enter application data on behalf of the applicant are not eligible for the 75% match. Only individuals who are authorized by the single state agency to enter data other than application elements into the eligibility system, who have responsibility for evaluating data in order to make an eligibility determination, who are authorized to exercise discretion in the evaluation of data, who are authorized to make an eligibility determination and who are accountable to the single state agency for such determinations are eligible the 75% match for those activities. This includes eligibility workers, whether in house or out-stationed, as long as there is a formal, written agreement with the single state agency that authorizes their eligibility activities and specifies direct lines of accountability to the single state agency. Both intake workers and on-going eligibility workers who meet these requirements may be claimed at 75%, based on appropriate cost allocations.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92656

The Affordable Care Act established an income disregard equal to five percentage points of the FPL disregard "for the purposes of determining income eligibility" for individuals whose eligibility is based on MAGI. In our final rule issued July 15, 2013, we provide that the disregard is applied to the income calculation of individuals only to the extent that the disregard matters for the purposes of determining eligibility for Medicaid or CHIP under MAGI-based rules-that is, those for whom the application of the disregard means the difference between being eligible for Medicaid or CHIP and being ineligible.

The disregard matters for purposes of determining Medicaid or CHIP eligibility only in cases where individuals have MAGI-based income that is above the highest applicable income standard under the program (Medicaid or CHIP), but would be within that income standard if the disregard were applied. This is the case only when the MAGI-based income is no higher than five percent of the FPL higher than that income standard. The disregard would not be applied for a determination of the particular eligibility group in which the individual qualifies, but only for overall eligibility for Medicaid or CHIP. We understand that this policy changes how disregards have been applied in the past, but believe this policy should be administratively simple to apply, for example, by applying the disregard at the point before a decision of ineligibility based on income would otherwise be made. This also ensures that the disregard does not reduce the "newly eligible" population for whom the increased federal matching rate is available.

For example, in a state that extends coverage to the new adult group, if a parent applied and has MAGI-based income within five percentage points of the FPL above the net income standard for the mandatory parent/caretaker relative group, the disregard would not apply because the disregard would not be needed for eligibility. The parent could be made eligible in the adult group instead. In that same state, if a parent applied with MAGI income within five percentage points of the FPL above the net income standard for the adult group (133% FPL), the five percent disregard would be applied to ensure that the parent could obtain eligibility in Medicaid and the parent would be made eligible in the adult group.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92591

No. The 75%/25% matching rate for eligibility systems is limited by the statute to activities directly related to an eligibility determination. A level of care assessment is not directly related to the eligibility determination. Although the assessment itself is not eligible for the 75% match, the entry of the level of care result into the eligibility system may be matched at 75%.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92646

Yes, 75 percent FFP is available for ongoing costs of operating approved eligibility determination systems, often referred to as "E&E" systems, that meet the Standards and Conditions for Medicaid IT and critical success factors. (See: State Medicaid Director Letter on APD Requirements dated June 27, 2016 (SMD# 16-009), to be found at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html.

Section 1903(a)(3)(B) of the Social Security Act provides 75 percent FFP for costs associated with operating an approved Medicaid management information system (MMIS). The Medicaid manual further clarifies at Section 11276.3 A. MMIS Operations, "FFP at 75 percent is available for direct costs directly attributable to the Medicaid program for ongoing automated processing of claims, payments, and reports. Included are forms, use of system hardware and supplies, maintenance of software and documentation, and personnel costs of operations control clerks, suspense and/or exception claims processing clerks, data entry operators, microfilm operators, terminal operators, peripheral equipment operators, computer operators, and claims coding clerks if the coded data is used in the MMIS, and all direct costs specifically identified to these cost objectives. Report users, such as staff who perform follow-up investigations, are not considered part of the MMIS."

States may claim 75 percent FFP for the costs of certain personnel closely associated with operating claims processing and related systems under MMIS. As noted in our final rule, Medicaid Program; Federal Funding for Medicaid Eligibility Determination and Enrollment Activities (CMS-2346-F), in response to comments, "enhanced funding is available for staff time spent on mechanized eligibility determination systems in the same manner that they apply to all mechanized claims processing and information retrieval systems, since mechanized eligibility determination systems are now considered to be part of such systems, assuming the requirements of this section are met." (See: https://www.federalregister.gov/articles/2011/04/19/2011-9340/medicaid-program-federalfunding-for-medicaid-eligibility-determination-and-enrollment-activities ).H59 Additional information on FFP rates, including tables delineating specific covered costs, is available in the State Medicaid Director Letter on Enhanced Funding dated March 31, 2016 (SMD# 16-004), to be found at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html.

States should work closely with CMS during the APD process to provide appropriate documentation concerning their cost allocation and claiming plans. In states where workers determine eligibility or provide customer service for multiple health and human service programs, costs should be allocated across programs, as discussed further in FAQ# 40811.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93696

Eligibility for the enhanced FFP will be based on state systems being compliant with the Standards and Conditions for Medicaid IT, including meeting minimum critical success factors for accepting the new single streamlined application, making MAGI-based determinations and coordinating with Marketplaces. The 75 percent FFP will generally be available when the approved system becomes operational. The 75 percent FFP will not expire.
The start date for the 75 percent FFP for maintenance and operations is the actual start of the operations of the approved eligibility determination system (also referred to as "E&E" system).

We recognize states may be phasing in system upgrades that implement modified adjusted gross income (MAGI)-based eligibility determinations first, with subsequent releases to include non-MAGI and/or other human services programs eligibility. We will allow the 75 percent FFP to begin with the start of the approved MAGI shared eligibility service, based upon an approved Operations APD, that meets the critical success factors. Further, states with challenges in meeting critical success factors at the expected service level must have approved mitigation strategies in order to qualify.

In order to begin claiming, states should submit an Operations APD to CMS that clearly identifies the functions, staff and costs to be charged at the 75 percent FFP level, and it must be approved by CMS before a state can begin claiming the enhanced match.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93701