Frequently Asked Questions

Yes. Under the Medicaid mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act, insured children must be covered in addition to uninsured children (please also see applicable match rate questions below). This is different from the rules governing a separate CHIP program, which preclude coverage for insured children.

Supplemental Links:

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

FAQ ID:92616

No. States continue to have the option to cover children above 133 percent of the FPL either under a Medicaid expansion or separate program. States must maintain CHIP "eligibility standards, methodologies, and procedures" for children that are no more restrictive than those in effect on March 23, 2010 as specified under the "maintenance of effort" provision at 2105(d)(3) of the Act. A parallel requirement in Medicaid can be found at sections 1902(a)(74) and 1902(gg) of the Act. These provisions are effective through September 30, 2019.

Supplemental Links:

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

FAQ ID:92621

Yes. The CHIP enhanced FMAP will continue to be available for children whose income is greater than the Medicaid applicable income level (defined in section 457.301 and based on the 1997 Medicaid income standard for children) after these children transition to Medicaid. This includes children who previously qualified for CHIP in a separate program and uninsured children whose family incomes are up to 133 percent of the Federal poverty level, and therefore will be eligible for Medicaid in 2014. Regular Medicaid matching rates will apply for all other children covered under the mandatory group for children aged 6-18-children with income no more than 100 percent FPL and insured children with income above 100 percent to 133 percent FPL.

Supplemental Links:

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

FAQ ID:92626

Yes. States that are transitioning children from a separate CHIP to the Medicaid state plan under the mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act (which will be part of the newly consolidated mandatory group for children at 42 CFR 435.118), will need to submit both a Medicaid and CHIP SPA. The Medicaid SPA will need to be approved prior to, or simultaneously with, the CHIP SPA.

In addition, states that currently cover uninsured children aged 6-18 with income above 100 percent to 133 percent FPL under the Medicaid eligibility group for optional targeted lowincome children at section 1902(a)(10)(A)(ii)(XIV) of the Act (42 CFR 435.229) will need a Medicaid SPA to transition these children to the mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act under the mandatory children's consolidated group at 42 CFR 435.118 and must expand their coverage to include insured children.

The SPA templates are available at http://www.medicaid.gov/State-Resource-Center/Medicaidand-CHIP-Program-Portal/Medicaid-and-CHIP-Program-Portal.html and CMS is available to provide technical assistance to states as they work through this transition.

Supplemental Links:

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

FAQ ID:92631

In order to ensure a smooth transition of children from a separate CHIP to Medicaid state plan coverage, we encourage states to consider the following points as they prepare for this transition. CMS will work with states on these issues as part of the CHIP SPA review process:

• Proper and timely notification to families, including detailed information on changes related to managed care plans, providers, benefits and cost sharing and what families can expect and need to do in preparation for the transition.
• Education and notification to key stakeholders, including providers, managed care plans, and carve outs, such as mental health or dental services.
• Establishment of a help line to address questions from families during the transition.
• Continuity of care for children in treatment, such as the transfer of prior authorization requests from CHIP to Medicaid providers.

Supplemental Links:

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

FAQ ID:92636

Yes. While coverage of children protected by 2101(f) is mandated through a separate CHIP, states may instead continue to provide coverage of these children in the state's Medicaid program, thereby eliminating the need to provide coverage in a separate CHIP in accordance with section 2101(f).

If a state chooses this option, children in the state would not lose Medicaid eligibility due to the elimination of disregards under the new "modified adjusted gross income" (MAGI) based methodologies. A Medicaid SPA could cover such children as an optional reasonable classification of children under 42 CFR section 435.222, with a disregard of all income (so that there would be no required determination of income).

The state will need to accurately identify the population of children who otherwise would lose Medicaid eligibility effective January 1, 2014 due to the elimination of income disregards as the new optional reasonable classification of children covered under this group. Children covered under this classification would remain categorically eligible based on their enrollment in Medicaid on December 31, 2013.

In order to limit the protection afforded under this strategy to the same timeframe as the protection which otherwise would be afforded to each affected child under a separate CHIP, the state may define this group as "children who would lose Medicaid eligibility on the initial redetermination of income using MAGI-based income determination due to the elimination of income disregards." The classification would thus not include individuals whose income is being redetermined after that time. This would be parallel to the treatment of this population in a separate CHIP, as automatically eligible in CHIP only when initially losing Medicaid eligibility.

For SPA page S52 for optional reasonable classifications of children that will be submitted for Medicaid state plan eligibility in 2014, the state should enter information for this new reasonable classification of children, just like it will enter information for any other reasonable classification covered by the state. The state would define this reasonable classification using the approved state plan language and would enter that no income test is used for this classification because there was no income test (i.e., all income was disregarded) in 2013.

In addition, once the Medicaid SPA has been approved, interested states should also submit a CHIP SPA (CS14) and check the first option indicating that: "The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision."

A state interested in covering children protected by section 2101(f) of the ACA should indicate its interest to CMS on its next State Operations and Technical Assistance (SOTA) call.

Supplemental Links:

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

FAQ ID:92641

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

Section 4004(i) requires the Department of Health and Human Services (HHS) to provide guidance to states and health care providers regarding preventive and obesity-related services that are available to Medicaid enrollees, including obesity screening and counseling for children and adults.

It also requires states to design public awareness campaigns to educate Medicaid enrollees regarding the availability and coverage of preventive and obesity-related services, with the goal of reducing incidences of obesity.

Lastly, it requires HHS to submit a Report to Congress every three years, beginning on January 1, 2011, which addresses the status and effectiveness of the activities above, including summaries of state efforts to increase awareness of coverage of obesity-related services. The 2014 report can be found at: https://www.medicaid.gov/sites/default/files/medicaid/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf (PDF, 133.39 KB).

Ways CMS helps states meet these requirements include the following:

1. CMS hosts a series of calls and webinars to support state efforts to inform Medicaid enrollees regarding coverage of preventive services. These calls provide an opportunity for states to share and learn about best practices for education and outreach campaigns, obesity-prevention initiatives, and other Medicaid and CHIP disease prevention activities.
2. CMS develops fact sheets that address Medicaid coverage of preventive and obesity-related services, which states can personalize and share with providers and other stakeholders.
3. CMS collects and disseminates examples of state Medicaid program efforts to increase awareness of preventive services.
4. Additional written resources are published on the Prevention page on the Medicaid.gov website: https://www.medicaid.gov/medicaid/benefits/prevention/index.html
5. Technical assistance questions can be sent to: MedicaidCHIPPrevention@cms.hhs.gov

Supplemental Links:

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

FAQ ID:92661

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.

Supplemental Links:

• 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.

Supplemental Links:

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

FAQ ID:92671