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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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.

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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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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Below are several options states may consider in implementing section 2101(f). Under each, the state may not find such children ineligible for a separate CHIP based on current or recent insurance coverage or other state-specific restrictions on eligibility. The only restrictions on CHIP eligibility that may be applied to the protected children are those described above in response to Question 5: "Do these children automatically meet the definition of a "targeted low-income child" regardless of other CHIP eligibility factors?"

Option #1: Demonstrate that all Medicaid children qualifying for section 2101(f) protection will qualify for the state's existing separate CHIP.

States with an existing separate CHIP may be able to demonstrate that the income standard for the state's separate CHIP (after conversion for MAGI) is sufficiently above the state's converted Medicaid standard for children that all, or virtually all, children losing Medicaid as a result of the loss of disregards under MAGI will be income-eligible for the state's separate CHIP. The state would need to demonstrate that most if not all affected children would be eligible for the state's separate CHIP without any modification of the program. Note that because state Medicaid programs may cover children in different age ranges (under 1, ages 1- 5, and ages 6-18) up to different income standards, this analysis would need to be done separately for each age range.

Under this option, States would also need to develop procedures to ensure that children being transferred from Medicaid to CHIP after a loss of Medicaid eligibility at their 2014 redetermination are not denied CHIP based on eligibility criteria which may not be applied to these children in accordance with section 2101(f) (see Question 5).

Option #2: Enroll all children in a separate CHIP who lose Medicaid due to income at their first renewal applying MAGI methods.

States can elect to enroll all children into CHIP who lose Medicaid eligibility because of excess income after applying MAGI-based income methodologies and the converted MAGIbased income standard under Medicaid. This option will capture more children than strictly defined under this provision (i.e. children losing Medicaid because of families' increased earned income will also be included) but may be the easiest option to implement administratively.

Option #3: Determine an income standard above the converted MAGI Medicaid FPL that will capture all or almost all the children who would have benefited from application of the former disregards.

Option #4: Identify protected children using 2013 data.

If, upon renewal, the state finds a child ineligible for Medicaid but that child's family income has not increased since the child's last determination of Medicaid eligibility in 2013 (i.e., prior to the application of MAGI-based methods in 2014), the state would automatically enroll the child in its separate CHIP. If the family income has increased since the last Medicaid determination in 2013, the state would identify children protected by section 2101(f) by subtracting the value of the allowed disregards the child received during the 2013 determination from the child's household income based on MAGI in 2014. If the adjusted household income (i.e., 2014 MAGI-based household income minus the value of former disregards in 2013) is at or below the income standard in effect in 2013 for the Medicaid eligibility group under which the child was enrolled, the state would enroll the child in the separate CHIP.

CMS will work with states to ensure the selected option is implemented correctly as we recognize that there must be significant collaboration between Medicaid and CHIP agencies to implement 2101 (f). We are also open to considering alternative proposals from states for how to implement this provision. States are strongly encouraged to talk with CMS in advance of submitting their state plan amendments to implement this provision.

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Yes. However, the benefit package and cost-sharing structure must be in compliance with separate CHIP rules.

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Yes, states will need to submit a CHIP SPA for approval to provide coverage to children under this group in accordance with section 457.60. CMS will make available a simplified SPA template on which the state may report how these protected children will be identified and enrolled and information on benefits and cost-sharing.

Because of the flexibility provided states in establishing eligibility for separate CHIP programs, states could establish a group within an existing separate CHIP or as a standalone separate CHIP with eligibility criteria specific to the chosen option. For example, a state could establish a CHIP group with eligibility limited to children losing Medicaid at their 2014 redetermination using MAGI methodology. Coverage provided under this group would sunset when the last child eligible for 2101(f) protection came up for their first annual renewal in CHIP.

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Yes. States will need to conduct a renewal at the end of the 12-month separate CHIP coverage period in accordance with section 457.343 to determine if the child remains eligible for CHIP and, if not, to determine potential eligibility for other insurance affordability programs and transfer the child's account, as appropriate, to the Medicaid agency or the Exchange.

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As noted above, the protection afforded under section 2101(f) extends until the child comes up for his or her first regular renewal for coverage under the separate CHIP program, which would be 12 months from the child's transfer from Medicaid to the separate CHIP. When the last child eligible for protection under section 2101(f) comes up for renewal in the separate CHIP, the state may discontinue this part of its program.

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No. Systems programmed to determine eligibility based on 2013 rules would not properly determine eligibility based on MAGI methodologies and therefore could not be used to identify these children. Children protected by section 2101(f) are children who lose Medicaid eligibility after MAGI rules (including household composition and family income) are applied but would have remained eligible if the former disregards had also been applied.

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No. Section 2101(f) does not apply to children made ineligible for a separate CHIP as a result of the elimination of income disregards. Children losing coverage under a separate CHIP must be screened for eligibility for other insurance affordability programs and their cases electronically transferred per section 457.348.

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