Frequently Asked Questions

Preventive services include immunizations, screenings for common chronic and infectious diseases and cancers, clinical and behavioral interventions to manage chronic disease and reduce associated risks, and counseling to support healthy living and self-management of chronic conditions, such as those associated with obesity. A list of preventive health care services recommended as Grade A or B by the U.S. Preventive Services Task Force can be found at: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/.

Through Medicaid's children's benefit - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - children under age 21 enrolled in Medicaid are assured coverage for preventive and comprehensive health services. States cover adult preventive services within Medicaid through both mandatory and optional benefit categories. Some preventive services (such as those related to family planning) may be defined in a state's mandatory set of benefits while others may be included in the optional benefit category. As a result, Medicaid programs differ from state to state on the coverage of preventive services for adults.

Obesity-related services are those services that help prevent and manage unhealthy weight. Medicaid and CHIP programs can cover a range of services to prevent and reduce obesity including Body Mass Index (BMI) screening, education and counseling on nutrition and physical activity, prescription drugs that promote weight loss, and, as appropriate, bariatric surgery.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 86.67 KB)

FAQ ID:92666

Affordable Care Act Section 4004(i)(2) calls for "state public awareness campaigns to educate Medicaid enrollees regarding availability and coverage of preventive and obesity related services with the goal of reducing incidences of obesity." The statute tasks states with designing the public awareness campaign because states have a better understanding of what outreach efforts will best meet the needs of their state Medicaid and CHIP population. Activities that provide information to beneficiaries about the preventive and obesity-related services covered in the state's Medicaid and CHIP programs will satisfy the requirement. Federal funding would be available for such activities as administrative costs of the Medicaid and CHIP programs.

Some resources that states may want to consider as they move forward with their activities include:

• Healthy Weight, Healthy People, Healthy Communities page on the Health Resources and Services Administration's website
• Centers for Disease Control and Prevention's Nutrition, Physical Activity and Obesity 
• "F as in Fat: How Obesity Threatens America's Future 2012," issued by the Trust for America's Health and the Robert Wood Johnson Foundation

States can receive the 50 percent Medicaid administrative matching rate for public awareness campaign activities, and will receive their existing Federal Medical Assistance Percentage (FMAP) rate for preventive services.

The Affordable Care Act includes additional funding for states that cover Grade A and B recommended services of the US Preventive Services Task Force (USPSTF) and all Advisory Committee on Immunization Practices (ACIP) recommended adult vaccines and their administration without cost sharing. CMS has released separate guidance on that provision which can be found at https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SMD-13-002.pdf (PDF, 138.73 KB).

In addition, CMS can provide technical assistance to states with reporting and interventions that they have in place to improve performance on the prevention core measures.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 86.67 KB)

FAQ ID:92671

Yes, if a state has undertaken an initiative to provide information on Medicaid coverage of preventive services since the passage of the Affordable Care Act in March 2010 then they have met this requirement.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 86.67 KB)

FAQ ID:92676

The Affordable Care Act provides significant federal support to ensure the availability of coverage to low-income adults. Enrollment caps limit enrollment in coverage on a first come, first serve basis. Periods of ineligibility delay or deny coverage for otherwise eligible individuals. These policies do not further the objectives of the Medicaid program, which is the statutory requirement for allowing section 1115 demonstrations. As such, we do not anticipate that we would authorize enrollment caps or similar policies through section 1115 demonstrations for the new adult group or similar populations.

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

FAQ ID:93751

Demonstrations focused on changes to how health care services are delivered, such as the use of managed care, will not generally affect the state's matching rate. Please refer to our February 2013 FAQs (PDF, 135.35 KB), which provide further clarification on the two increased federal match rates: the newly eligible rate and the expansion state rate as well as the final FMAP rule published on April 2, 2013. Additionally, CMS issued two State Medicaid Director letters, on July 10, 2012, that provide guidance on how states can adopt integrated care models without the need for a section 1115 demonstration.

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

FAQ ID:93756

Effective January 1, 2014, MAGI eligibility rules will be used to determine eligibility for nonelderly, nondisabled eligibility groups. The transition to MAGI also involves converting current net income eligibility standards to MAGI standards. MAGI rules apply regardless of whether a state adopts the new adult eligibility group. The December 28, 2012 Modified Adjusted Gross Income (MAGI) conversion guidance (PDF, 177.59 KB) sets out options for a state to use a standardized MAGI conversion methodology (using Survey of Income and Program Participation (SIPP) data or with state data) or to propose an alternative methodology for converting to MAGI.

There are two potential ways of using the standardized MAGI conversion methodology:

• States may choose to have CMS calculate the converted income levels for eligibility groups requiring conversion using state-adjusted data from the Census Bureau's SIPP; or
• States may choose to use their own data as the source for applying the standardized conversion methodology.

For each eligibility group income level that needs to be converted, under the standardized MAGI conversion methodology, individuals whose net income is within 25 percentage points of the FPL below the current income standards will be selected (for example, if the current standard is 80 percent of the FPL, the analysis will include people with incomes between 55 and 80 percent FPL). The next step is to calculate disregards as a percent of FPL for each selected individual. The resulting average disregard amount as a percent of FPL is added to the current net income standard to get the converted standard.

For example, if the average disregard is 8 percent FPL, the converted standard would be 88 percent FPL. This basic process is the same regardless of whether SIPP data or state data is used.

Alternatively, states have the option to propose their own method, subject to approval by CMS. States are asked to provide a statement of intent by February 15, 2013 and must submit their MAGI conversion plans by April 30.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93931

Factors that states might want to consider in choosing an income conversion method and data source include whether the state currently maintains or can easily access the data that are needed to do the conversions, as well as the quality and completeness of the state's data. In addition, states will want to consider whether they have the analytical resources needed to do the conversions with their own data, how long it would take them to run the conversions and how much it would cost to pay a contractor to do the analysis. Finally, states should also consider preferences about using state-adjusted SIPP or state data.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93936

Detailed information on how to use state data to apply the standardized conversion methodology is forthcoming, but in general states will need 1) information on net income of each person and the size of the Medicaid eligibility unit to establish which enrollees fall within the 25 percentage point band below the current net income standard; and 2) data on the total amount of disregards for each individual within the 25 percentage point band - if this is not stored as a data element in the state's system, this can be calculated by adding up individual disregards, or as the difference between gross income and net income.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93941

Technical assistance for states thinking through their MAGI conversion options is available through the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota. SHADAC is available to help states understand the income conversion methods, the data sources that can be used (SIPP or state data), and factors for states to consider in choosing a methodology. CMS will do conversions for all states using the standardized conversion methodology with SIPP data. States that choose to use state data or that propose a different methodology will need to do the conversions themselves, and SHADAC is available to provide consultation with states as they work through the process. This help is available at no cost to states. States can contact SHADAC for help with income conversion at (612) 486-2439 or by emailing their questions to fmaphelp@shadac.org.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93946

To produce reliable state-level results, income conversions using SIPP data will be based on the entire national sample that has been re-weighted to account for state demographic characteristics. The purpose of the reweighting is to ensure that the analysis is done using a population whose characteristics are similar to each state's actual population. The variables used in reweighting include age, parent status, gender, race/ethnicity, total household income as a percent of FPL, types of unearned income (whether the household has any unearned income and whether it includes child support), and whether or not an individual has child care expenses. The re-weighting will be done separately for each state and will ensure that the distribution of these characteristics (and combinations of these characteristics) matches state totals from the Census Bureau's Current Population Survey. In some states, a few of these categories will need to be combined due to small sample size. CMS will be releasing a brief on SIPP and the re-weighting adjustments.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93951