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
What if I encounter an account that does not appear to fit into any of a state's eligibility coverage groups?
Applicants that indicate they have a disability, need long-term care or are over age 65 are always referred to the Medicaid agency for a determination on a non-MAGI basis, regardless of income and household composition, since the FFM is evaluating eligibility for MAGI-based eligibility groups only. Additionally, applicants may always request a full Medicaid determination at the end of the application process. In assessment states, the Medicaid agency will do a final determination of eligibility for these applicants, whereas in determination states, the Medicaid agency just needs to follow up for a non-MAGI determination. The expanded flat file will contain a specific indicator showing if the applicant requested a full determination.
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FAQ ID:92136
SHARE URLIf a state's inpatient hospital, outpatient hospital, or nursing facility Upper Payment Limit (UPL) demonstration has been approved by CMS for demonstration year 2018, does the UPL template still need to be populated and submitted for 2018?
No, states that already have submitted their 2018 (07/01/2017 - 06/30/2018) inpatient hospital, outpatient hospital, or nursing facility services UPL demonstrations will not have to resubmit using the templates. In that instance, CMS will populate the templates using data already submitted by the state.
FAQ ID:92211
SHARE URLOur state covered institutions for mental disease (IMD) under the inpatient hospital and nursing benefit. Should we conduct a separate UPL for these facilities?
No, facilities that are licensed, covered, and paid under the Medicaid state plan as inpatient hospital or nursing facilities should be included in the UPL calculated for those services. There is no regulatory requirement to conduct separate calculations for designated facility "types" within each of the applicable service categories. States do not need to provide separate UPL demonstrations for IMDs covered under the inpatient hospital or nursing facility services benefit.
FAQ ID:92381
SHARE URLCan states rely on the information contained in the enhanced flat files?
We believe these files have information that states can rely on. As with any transmission of data or logic process, discrepancies may arise. However, we have done quality reviews and continue to act on reports of issues as quickly as possible by investigating them and introducing systems fixes as needed. We are continuing our testing and quality assurance efforts as well. We expect that states will be doing the same on accounts transferred from states to the FFM. We will continue to rely on our daily desk officer calls and our SOTA process to follow up with states on any questions that may arise.
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FAQ ID:91906
SHARE URLWhat action may the state take if the state believes there is another basis for excluding an individual from flat file-based enrollment based on state analysis or external information?
If the state would like to exclude individuals from enrollment based on the flat file, please reach out to CMCS to discuss the state's options. Our goal in offering this flat file option is to provide an additional avenue for enrollment and we will work with states on how they might best maximize the use of these files.
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FAQ ID:91921
SHARE URLWhat if a state later determines that a person enrolled based on information in the flat file is not eligible for Medicaid or CHIP?
In a letter dated November 29, 2013, (see http://www.medicaid.gov/Federal-PolicyGuidance/downloads/SHO-13-008.pdf (PDF, 117.76 KB)) CMS offered states the opportunity to apply for a waiver under section 1902(e)(14)(A) of the Social Security Act to allow them to make temporary enrollment decisions based on the information included in the flat file. So, as long as states follow the procedures outlined in the guidance and other applicable rules with respect to eligibility and claiming, federal funding is available for this temporary enrollment. Individual's circumstances might change and other factors might arise that could change the outcome of the eligibility determination once the state evaluates eligibility based on the full account transfer. Federal funding is not at risk for states that follow appropriate procedures to enroll beneficiaries based on the FFM's determination or assessment of eligibility.
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FAQ ID:91926
SHARE URLWe understand that if we use the expanded flat file for enrollment, applicants are eligible to receive Medicaid for 90 days for assessment states and that we will run them through a MAGI-based determination in the future. If we enroll someone based on the flat file, and then become aware of additional information regarding the individual's eligibility before we receive the full account transfer, do we need to act on that information?
Since the waiver is a temporary grant of authority, if changes in circumstance are reported then states have the flexibility to choose to act on reported changes immediately or wait until the full determination occurs. If a state has the capability to review and process the changes reported they can do so, and if a state does not wish to act upon reported changes during this temporary waiver period that is also permissible. States should discuss with CMS how to document the state's policy regarding changes in circumstance in the waiver request.
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FAQ ID:91931
SHARE URLIf an application contains a household which is a mixed case with MAGI and non-MAGI individuals, how should the state process enrollment in this situation?
Because the Federally Facilitated Marketplace (FFM) is providing eligibility determinations/assessments for Medicaid under the MAGI standard, the state can process enrollment for MAGI individuals under the waiver authority. Since the FFM is providing non-MAGI applicant referrals on the expanded flat file, the state would act upon the non-MAGI referrals in the same manner as it would through the account transfer service.
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FAQ ID:91936
SHARE URLWhat are the security requirements for receiving and acting upon the expanded flat file? Can we follow processes consistent with paper applications (logging starts once the information is entered into the eligibility system)?
Yes, all the regulations and security constraints that apply to paper applications are necessary with the expanded flat file. The state would need to maintain the same level of security for the expanded flat file as they would in regard to paper applications.
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FAQ ID:91941
SHARE URLWhat if an account contains an out of state address?
Applicants can apply for whatever state they choose. Sometimes someone will want to file an application for a state they don't currently live in. For example, if they are temporarily residing outside the state or have a family member or tax dependent that needs coverage who lives there. When an applicant applies on the Federally Facilitated Marketplace (FFM), they provide their home address and that information is used to validate the eligibility criteria of state residency during the eligibility determination process. If an applicant does not indicate they have a home address in the state they are applying to, and they do not indicate they are temporarily absent from the state, they will be denied Medicaid, CHIP and APTC for that state in accordance with state and federal rules. However, an applicant can always request a full determination, and in doing so, the account is transferred to the state indicated. In order to respond, the state will need to verify residency, and approve or deny Medicaid as applicable.
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FAQ ID:91946
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