Implementation Guides - Centers for Medicare & Medicaid ...



Statute: 1902(a)(10)(A)(ii)(XX), 1902(hh)

Regulation: 42 CFR 435.218

INTRODUCTION

This state plan page (fillable PDF) describes the new optional eligibility group for individuals under age 65, with household income above 133% FPL, but no higher than a standard established by the state for this group. Individuals qualify under this group only if they are not eligible and enrolled for any mandatory group or other optional eligibility groups covered under the state plan. States may elect to phase-in the implementation of this group by population and/or income limit.

BACKGROUND

Section 2001(e) of the Patient Protection and Affordable Care Act of 2010 (ACA) adds a new section 1902(a)(10)(A)(ii)(XX) of the Social Security Act. This section gives states the option, starting in 2014, of providing Medicaid to individuals under age 65 (including pregnant women and children) with income above 133 percent FPL. Individuals eligible under this group cannot be eligible for or enrolled in any mandatory group or any other optional group listed in section 1902(a)(10)(A)(ii)(I) through (XIX) of the Act that is covered under the state plan (not including the Individuals Eligible for Family Planning Services and Medically Needy). If a state has not voluntarily elected to cover the Adult Group (42 CFR 435.119), it may not elect to cover individuals under this optional group, who would have income exceeding the income limit of 133% FPL for the Adult Group.

This eligibility group uses MAGI-based income methodologies to calculate countable income, rather than the previous AFDC-based methodologies. These methodologies are defined at S10 - MAGI-Based Income Methodologies.

This new eligibility group provides a simplified mechanism for states to cover all individuals under age 65 whose income exceeds the state's income standard for mandatory coverage (for example, 133 percent FPL for the Adult Group). This option is an alternative to the use of income disregards under section 1902(r)(2) or 1931(b)(2)(C) of the Act, which have been used in the past to expand eligibility, but which will no longer be available for the various eligibility groups using MAGI-based income methodologies starting in 2014.

A state may choose to grant coverage to individuals eligible under this group using “presumptive eligibility,” but only if it has already elected to use presumptive eligibility determinations for either or both of the following groups:

• Pregnant women; and/or

• Infants and children under 19.

TECHNICAL GUIDANCE

PREREQUISITES:

• S32 – Adult Group must be completed, with the choice of Yes, electing to cover the group, in order for this eligibility group to be approved.

• If the state chooses to cover individuals above 133% FPL when determined presumptively eligible, either S28 - Pregnant Women or S30 - Infants and Children under Age 19 must have presumptive eligibility selected as an option in order for this group to be approved with presumptive eligibility elected.

Review Criteria

The state must have elected to cover the Adult Group in the S32 State plan page, and completed that state plan page. If S32 is not completed, the SPA cannot be approved. If presumptive eligibility is selected as an option, it must have additionally been selected as an option in either S28 or S30.

The state must first indicate, Yes or No, that it elects to cover individuals in this optional eligibility group. A state that does not elect to cover this group must download this state plan page, check No and submit the state plan page. If the state selects Yes, additional text will be displayed which describes the eligibility group, including the options associated with it.

Review Criteria

Yes or No must be selected with respect to whether or not the state elects to cover this group. If Yes or No is not selected, the SPA cannot be approved.

The state must attest that it operates this eligibility group consistent with the criteria listed and choices selected in this state plan page. The state provides this affirmative attestation by checking the box immediately below the description of the group at the top of the state plan page.

Review Criteria

The state must check the box attesting that it operates this eligibility group consistent with the provisions selected on this state plan page. If the state does not check this box, the SPA cannot be approved.

This state plan page is divided into 7 major sections:

• The individuals qualifying under this group

• The income methodology used

• The income standard used

• The resource test used

• Restrictions for parents or other caretaker relatives

• Presumptive eligibility option

• Phase-in option

Individuals Qualifying under this Group

Individuals must meet the following criteria:

• Be less than 65 years old (Unlike the mandatory group, the Adult Group, this group does not have a lower age limit and does not exclude pregnant women and Medicare eligibles/recipients.);

• Not be eligible for or enrolled in Medicaid under one of the mandatory eligibility groups (for listings, see Mandatory Family/Adult Eligibility Groups and Mandatory Aged, Blind and Disabled Eligibility Groups);

• Not be eligible for and enrolled in Medicaid under one of the optional eligibility groups, under Options for Coverage category, based on information available to the state from the Medicaid application (for listings, see Optional Family/Adult Eligibility Groups and Optional Aged, Blind and Disabled Eligibility Groups), except for the Individuals Eligible for Family Planning Services group; and

• Have household income that exceeds 133% FPL, but is equal to or below a standard established by the state for this group.

Income Methodology Used

MAGI-based income methodologies are used for this eligibility group. A separate state plan page (S10 - MAGI-Based Income Methodologies) describes the MAGI-based income methodologies used by the state. Once completed, S10 applies to all eligibility groups using the MAGI-based income methodology. If the state wishes to make a change to the description of its MAGI-based income methodologies, it must navigate to S10 to make that change with this SPA.

Income Standard Used

States must enter the income standard used in determining eligibility for this group, which must be higher than 133% FPL.

Review Criteria

The state must enter a percentage amount of the Federal poverty level that represents the income standard for this group, and that percentage must be higher than 133% FPL. If no entry is made in this field or the entry is not higher than 133% FPL, the SPA cannot be approved.

Resource Test Used

No resource test is used for this eligibility group.

Restrictions for Parents or Other Caretaker Relatives

In order for a parent or other caretaker relative of a child under the age specified below to qualify, the child must already be covered under Medicaid or CHIP, or through the Exchange, or otherwise enrolled in health insurance at least at the level of minimum essential coverage, as defined in 42 CFR 435.4.

For this provision, the state must choose the applicable age of the child from the following two options:

• Under age 19; or

• Under a higher age, either 20 or 21, if this age was covered under the state plan as of March 23, 2010 under the regulations at 42 CFR 435.222 (see S52 – Reasonable Classifications of Individuals under Age 21).

NOTE: If the state did not cover all children under age 20 or 21 who met the state’s income standard under this optional group as of March 23, 2010, it may not choose to apply this provision at a higher age level now.

Review Criteria

The state must make the appropriate selection for the age of children who must be covered for health insurance in order for the parent or other caretaker relative to qualify under this eligibility group.

Presumptive Eligibility Option

In this section, the state indicates whether or not it covers individuals qualifying under this eligibility group if determined presumptively eligible.

NOTE: The state may not elect to cover individuals in this group presumptively unless it has already elected presumptive eligibility for either or both of the following groups:

• Pregnant Women (see S28 – Pregnant Women); and

• Infants and Children under the Age of 19 (see S30 – Infants and Children under Age 19).

Review Criteria

If the state checks Yes to covering this group as presumptively eligible, the SPA may not be approved unless the state has already submitted either S28 or S30 with the presumptive eligibility option, or one of those state plan pages is submitted with this SPA.

If the state has elected Yes to the presumptive eligibility question, additional text is displayed:

Beginning and Ending Dates

• The rules are presented for the beginning and ending dates of a presumptive eligibility period.

Presumptive Eligibility Periods

• The state must select from one of the options presented how it limits the number of presumptive eligibility periods that an individual may receive (e.g., one every 12 months, or one every calendar year).

• If none of the options fits the state’s method of limiting the number of periods, the state should select Other reasonable limitation.

The state may have more than one other reasonable limitation (press the + sign to add and the X sign to remove). For each one, it must enter:

o A name for the limitation (this can be any name that relates to the limitation and makes sense to the state); and

o A description of the limitation.

Review Criteria

The state must select one of the options for its limits on presumptive eligibility periods. If it selects “Other reasonable limitation” it must name any such limitation and provide a description. The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the State’s election meets applicable federal statutory, regulatory and policy requirements.

Application

• The state must indicate whether or not it requires a written application for presumptive eligibility, rather than just a verbal application.

If Yes is selected, the state must additionally select whether that application is:

o The single streamlined application form (as defined in 42 CFR 435.907) used for Medicaid eligibility, approved by CMS; or

o A separate application form for presumptive eligibility, which must be approved by CMS.

If the separate application for presumptive eligibility is selected, the state must upload a copy of it.

Review Criteria

If the state requires a written application for presumptive eligibility, it must select one of the options presented. If the second option is selected, the state must also upload a copy of the separate application form it intends to use specifically for presumptive eligibility. The SPA cannot be approved unless this application is uploaded and is approved by CMS.

PE Eligibility Factors

• The state is required to identify the factors upon which the presumptive eligibility determination is based. Two of those factors are mandatory:

o The individual must meet the categorical requirements of 42 CFR 435.218.

o Household income must not exceed the applicable income standard described at 42 CFR 435.218 and indicated above.

In addition to the above mandatory factors, the state may elect to base presumptive eligibility on either or both of the following optional factors. Neither is required.

o State residency; and/or

o Citizenship, status as a national, or satisfactory immigration status.

Qualified Entities

• Qualified Entities must be used to determine presumptive eligibility for this group.

▪ A list of the potential types of qualified entities will be displayed. From this list, the state selects the types of entities it uses to determine presumptive eligibility for this eligibility group. One or more may be selected.

▪ If the state uses a type of entity not listed, it should select “Other entity the agency determines is capable of making presumptive eligibility determinations”.

▪ The state may use more than one “Other” entity (use the + sign to add and the X sign to remove).

▪ For each additional type, the state must enter:

• A name for the type of entity (this can be any name that relates to the entity and makes sense to the state); and

• A description of the entity. The description should include why the state believes this entity is qualified to determine presumptive eligibility, including such factors as knowledge of Medicaid policy and experience with Medicaid beneficiaries.

Review Criteria

The description should explain why the state believes this entity is qualified to determine presumptive eligibility, including such factors as knowledge of Medicaid policy and experience with Medicaid beneficiaries. The description must be sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s election meets applicable federal statutory, regulatory and policy requirements.

Attestation

• The state must assure that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities involved. The state provides this affirmative assurance by checking the box immediately to the left of this text.

The state must attach to the SPA submission a copy of its training materials for review and approval by CMS (e.g., PowerPoint or webinar training slides, written instructions or manual for PE determinations), as part of the approval process for this state plan amendment.

Review Criteria

The state must check the box providing assurance that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. The state must also attach a copy of its training materials. If this box is not checked or the training materials are not provided by the state and approved by CMS, S50 cannot be approved.

Phase-in Option

In this section, the state may indicate its decision to phase-in coverage to individuals in this group.

• If the state selects No to the phase-in statement, the state plan page for this group has been completed and may be submitted for CMS approval.

• If the state selects Yes to the phase-in statement, the following set of data must be completed:

Review Criteria

The state must check Yes or No to the Phase-in option question. If it selects Yes, the rest of the section must be completed.

Basis of Phase-in

First, the state must select whether the phase-in will be done by groups of individuals, household income, or both. After the basis of the phase-in approach is selected, the state must click the button, Please CLICK HERE after all of the phase-in categories are entered.

Phase-in by Groups of Individuals

• If Phase-in will be done by groups of individuals is selected, the state must select one or more of the following groups to describe its phase-in process:

▪ Children

▪ If this is selected, the state must additionally select the age, with options ranging from under 18 to under 21. Only one age may be selected.

▪ Parents and other caretaker relatives of dependent children

▪ Non-pregnant individuals age 19 through age 64

▪ Pregnant women

▪ Other groups

• If this is selected, the state may choose to phase-in by more than one other group. For each one, it must enter a name for the group (this can be any name that relates to the group and makes sense to the state, such as the groups listed in section 1905(a) of the Act). At least one group name must be entered.

If this is the only choice for phase-in made, the state should press the Please CLICK HERE after all of the phase-in categories are entered. If not, the state should go on to check the household income choice, as well, and then press the button to indicate that all categories have been entered.

If the phase-in will only be done by groups of individuals, after the button is pressed, a table will appear with the selected groups listed. In this table, the state must enter:

• A number that corresponds to the order in which each group will be implemented. For example, if the state selects both Children under age 20 and Parents and other caretaker relatives of dependent children, they will appear in the table in the order previously selected. But if the state wishes to phase-in parents and other caretaker relatives first, and children second, it should place a 1 to the left of the parents and other caretaker relatives group and a 2 to the left of the children group.

• A target effective date to the right of each group, which represents the estimated date that this group will be phased-in. Click in the Target Date field next to the group and a down arrow will appear. Click on the arrow and a calendar will be presented.

Phase-in by Household Income

• If Phase-in will be done by household income is selected as the only option, the state should press the Please CLICK HERE after phase-in categories are entered. After the button is pressed, a table will appear for the state to enter income ranges, order and target dates. In this table, the state must enter:

▪ Order: Enter a number that corresponds to the order in which the indicated income range will be started. (“1” for the first group, “2” for the second group, etc.)

▪ Lower Limit FPL: Provide the FPL level that corresponds to the lower end of the income range, the income level at which individuals will be included in the phase-in group.

▪ Upper Limit FPL: Provide the FPL level that corresponds to the upper end of the income range, the income level up to which individuals will be included in the phase-in group.

▪ Target Date: Enter the target effective date for the indicated income range, which represents the estimated date this income range will be phased-in.

▪ Click the + sign to display another line to enter the next income range and repeat the above process for each income range in the phase-in.

Phase-in by Both Individuals and Household Income

• If both Phase-in will be done by groups of individuals and Phase-in will be done by household income are selected, the state must complete a table which provides an income range for each group selected, with an ability to enter the order and the target date for each line. The table displays the groups selected in a drop-down list. The state must:

▪ Select from the drop-down list which group it would like to describe first.

▪ Enter the first income range for that group, along with the order number and target date for that line.

▪ For additional income ranges for that group, click the + sign and select the group again and add the next income range for that group, along with the order number and target date. Continue to do this until all income ranges have been entered for that group.

▪ Select from the drop-down list the next group the state would like to describe, and follow the steps above to enter all the income ranges, order numbers and target dates for that group.

▪ Continue to follow this pattern until all of the groups and their income ranges have been entered.

Review Criteria

The state must select one or both of the phase-in options. If the first option is chosen the state must select one or more groups of individuals for the phase-in. If “other groups” is chosen the state must name the group or groups. If the state does not make a selection or, if “other groups” is selected, provide a name for the group, or the SPA cannot be approved. If only the first option is chosen, the state must also complete the table indicating the order of the phase-in of the groups.

If only the second option is chosen to phase in by income range, the state must make an entry in each of the fields to indicate the order, lower and upper FPL limits and Target Date for each income range that will be phased in. If the state does not complete these fields, the SPA cannot be approved.

If the state is phasing in by both groups of individuals and income ranges, the state must complete the combined table, indicating the income ranges for each group selected, as well as the order and target dates. The state must make the indicated selections and complete the fields with this information or the SPA cannot be approved.

Phase-in Final Target Date

Next, the state must enter a final phase-in date by which all individuals eligible under this group will qualify.

Review Criteria

The state must enter a final phase-in date. If this is not done, the SPA cannot be approved.

Additional Description

Finally, the state may, at its discretion, enter any additional description of the Phase-in Plan not covered by previous entries. This field is not required.

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