Modified Adjusted Gross Income (MAGI): Exchange and Medicaid Eligibility Flow Charts Updated per March 2012 Final Rules and June 2012 Supreme Court Decision October 3, 2012 1 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012 These charts illustrate MAGI eligibility processes for premium tax credits, cost-sharing reductions, and Medicaid eligibility. They also detail the new Medicaid eligibility groups, based on our interpretation of the regulations. The document highlights the areas where states have policy flexibility and where decisions need to be made by the State.
Transcript
Modified Adjusted Gross Income (MAGI): Exchange and Medicaid Eligibility Flow Charts
Updated per March 2012 Final Rules and June 2012 Supreme Court Decision
October 3, 2012
1 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
These charts illustrate MAGI eligibility processes for premium tax credits, cost-sharing reductions, and Medicaid eligibility. They also detail the new Medicaid eligibility groups, based on our interpretation of the regulations. The document highlights the areas where states have policy flexibility and where decisions need to be made by the State.
2 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Table of Contents
Legend
3 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
1
4
1
Household Size Info Found
Electronically?
Prior Enrollment
Flow Chart LEGEND
END
Yes No
Process Connector
Continued on to New Page
Process Decision Connector
Continued from Another Page
State Specific Comment
Process Description
Process End Indicator
Start Process Start Indicator
Determine Household Size Detailed Process Indicator
The Exchange must enter into agreements with Medicaid Agency to enable individual and dependents to be screened for Medicaid based on non-MAGI eligibility – example disability.
Regulation/Rule Brief
P#
P# Detailed Process Page #
State Decision Needed *#
138%* FPL 5% disregard included (For optional expansion, applies to Medicaid determinations only)
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Brief Coverage Area
Under PTC eligibility % of income indicates the % of income an individual is required to pay after which the PTC will cover remaining premium. For Cost-sharing this indicates the increased plan Actuarial Value (AV) an individual is eligible for based on a 70% AV silver plan. AV indicates the % of costs the plan covers vs. the individual. At 100% AV an individual has no cost sharing.
**
Coverage Option Overview
5 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Medicaid Categories • Children’s Group • Pregnant Women • Parent/Caretaker • Adult (State Option) • SCHIP • Former Foster Children
Tax Subsidy/Cost-Sharing
Reduction
Insured through Medicaid
Not Eligible for Assistance
Insured through Individual
Exchange Commercial Plan
Exchange
Non-Subsidized Individual
Coverage
Individuals enrolled in affordable employer sponsored coverage or eligible for minimal essential coverage through an employer are not eligible to receive advanced payments
for premium tax credits or cost sharing reductions.
The regulation consolidates eligibility categories for parents and other caretaker
relatives, pregnant women, and infants and children under age 19.
The Medicaid Agency must adopt the Modified Adjusted Gross Income (MAGI) calculation
methodology for all individuals applying for the new and consolidated Medicaid categories.
Individuals applying for coverage on the Exchange have the ability to decline to be
screened for eligibility for Medicaid, PTC and cost-sharing reductions.
In States that elect Medicaid expansion, Medicaid eligibility
extends to all non-Medicare eligible individuals under 138%* FPL and tax
credit eligibility extends from 138%*FPL to 400% FPL based on
MAGI.
Individuals can still be eligible for Medicaid based on disability or
other current Medicaid categories; their income would not be calculated
based on MAGI.
Off Exchange – Public
Assistance – Non MAGI
Medicaid
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
MAGI Calculation
7 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Request for Public
Assistance/Insurance
Access Federal HUB
MAGI Calculation
Below 400% FPL?
1
Independent Enrollment
through Exchange Public Assistance Enrollment
END
Start
Yes No
Check Citizenship/SSN
Check Incarceration
Check State Residency
Determine Household Size
Determine Household Income
Citizen, Not Incarcerated,
and State Resident?
Yes No
Denied Exchange Coverage
END
P14
P15
P16
P17
P19
The Medicaid Agency must adopt MAGI calculation methodology for all individuals applying for the new
and consolidated Medicaid categories.
Eligibility must be redetermined every 12 months.
When possible the agency must complete the redetermination without requiring
information from the individual.
Individuals that are determined not eligible for Medicaid must
be screened for advanced payments of PTC and cost-
sharing reductions.
Individuals who are in the process of being determined
eligible for Medicaid on a basis other than MAGI must be screened for eligibility in
Credits, and Cost Sharing Reductions) for interim coverage.
For Eligibility determinations the Exchange will rely on the federal hub for income and citizenship information, when available.
All individuals have the right to appeal any eligibility determination for
Medicaid, PTC, cost sharing subsidies, or QHP eligibility.
*1
8
In Medicaid, all unborn children counted in determining family size of pregnant women .
Eligible for Employer
Sponsored Plan?
Yes
No
Denied Exchange Coverage
END
If household tax filer does not verify applicants attestation, applicant will not be eligible for advanced payments of the
PTC or cost-sharing reductions.
Individual Case Approved?
No Yes
If an applicant’s attestation cannot be verified, the Exchange must review on a case by case
basis and provide exceptions, as appropriate, and an explanation of circumstances.
The Exchange must accept attestation if the discrepancy or difference does not impact the eligibility of the applicant.
The Exchange must verify whether an applicant is eligible for or enrolled in an employer-sponsored plan.
Non MAGI application or
trigger or request for non-
MAGI review?
2
Calculate FPL P20
Yes
No
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
*2
*2, 3, 4, 5
*6
At any FPL an Indian enrolled in a QHP is eligible for services without cost sharing from Indian Health Services, Indian Tribes, Tribal
Organizations, or Urban Indian Organizations. This special cost-sharing must be provided without the individual having to go through
the determination for insurance eligibility programs.
Includes verification of Indian status. Indians are eligible for reduced and special cost-sharing reductions and may not have to
complete subsidy eligibility process.
Does Not Request Medicaid
Eligibility Review?
Yes
No An applicant can have employer coverage and be MAGI Medicaid eligible or have ESI and Medicaid as payor of last resort (with exception to SCHIP).
No
MAGI Calculated Public Assistance Categories
1
Under 19 years old?
Children’s Group
Yes
No Pregnant?
Under State’s Income Threshold?
Minimum: Higher of 133% FPL or such higher income standard up to 185% FPL as of 12/19/89 or
7/1/89 had authorizing legislation Maximum: Higher of MAGI equivalent as of 3/23/10 or
3/23/13 income level if higher; or 185% FPL
Yes
Pregnant Women
Group
Parent/Caretaker? No
Yes
Under State’s Income
Threshold?
Minimum: AFDC income
standard as of 5/1/88
Maximum: MAGI equivalent
for 1931 families as of
3/23/10 or 12/31/13 or
7/16/96 AFDC income
standard increased by CPI
Parent/Caretaker
Relative Group
Yes
No
Between Parent/Caretaker
FPL & 138%* FPL?
Option: Adult Group
Have Child under 19 enrolled
in Medicaid or minimum
essentially covered?
Not eligible for Medicaid
Yes No
Option: Adult Group
END
Exchange Commercial Plan
250-400% FPL
No
Determine Tax
Subsidy
Yes
0-250% FPL? No
Yes
No
Between 0%-138%* FPL?
Yes
No
No
Yes
Yes
A new optional category is created for adults between 19 and 65 who are at or below 138%* FPL regardless of
caretaker status.
Under State’s Income Threshold?
Minimum: 133% FPL - or - for
infants under age 1 such higher
income standard as of 12/19/89
or 7/1/89 had authorizing
legislation
Maximum: Higher of 133% FPL;
MAGI equivalent of 3/23/10 or
3/23/13 income level if higher; or
for infants under age 1 185% FPL
9
The regulation consolidates eligibility categories for parents and other caretaker relatives, pregnant women, infants and
children under age 19. Non-consolidated mandatory and optional eligibility groups are maintained.
Below State’s SCHIP income threshold -or- Medicaid enrolled
child on 12/31/13 determined ineligible for Medicaid due to
elimination of income disregards?
Yes
SCHIP
No
Info on App suggests non-MAGI eligible or requests non-MAGI determination
or No Medicaid income determination
required?
2 Yes
*7, 8, 19
Under 26, in foster
care on 18th
birthday, Medicaid
enrolled while in
foster care?
Former Foster
Child Group
No
Yes
No
3
3 3
3
3
3
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
3 4
*19 *19
Non-MAGI Medicaid – Other Categories
2
No income determination
required by Medicaid (e.g., Title
IV-E, SSI, Express Lane)
10
Review for eligibility on basis
of blindness, disability,
medically needy coverage or
need for long-term services &
supports
Non MAGI application,
request for non-MAGI review
or application identifies
potential non-MAGI eligibility
Determined Eligible based on
disability/need for long term
services & supports?
Enrolled in applicable category Eligibility maintained in Adult
Group or Tax Subsidy
Application for Medicare
Savings Program?
Electronic case transferred
to Medicaid &enrolled in
Medicare Savings Program
Yes No
The regulation exempts from MAGI methodology individuals for whom Medicaid does not make an income
determination, Medicare Savings Program individuals, and individuals being determined eligible on basis of blindness,
disability or need for long-term services & supports.
END
END
Electronic Case Transferred
to Medicaid & enrolled in
applicable category
Electronic Case transferred to
Medicaid
Exchange notified of
Medicaid determination
Exchange notified of
Medicaid determination
Exchange notified of
Medicaid determination
END
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
OR Exchange have reason to believe eligible for Non-
MAGI Medicaid?
Referral to Non-MAGI
Medicaid
No Yes
END
11 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Between 100-133% FPL?
Yes No
12
END
MAGI Tax Subsidy Determination
If individual is an Indian below 300% FPL then individual is eligible for Cost Sharing Reduction to
100% of Plan AV.
DRAFT - Eligibility Process Flows -Based on our Interpretation of IRS NPRM 26 CFR PART 1 and February 2012 CCIIO Actuarial Value and Cost Sharing Bulletin
4
PTC** Cost Sharing **
2% of Income 94% Plan AV
Between 133-150% FPL?
Yes No
PTC** Cost Sharing **
3% of Income 94% Plan AV
Between 150-200% FPL?
Yes No
PTC** Cost Sharing **
4% of Income 87% Plan AV
Between 200-250% FPL?
Yes No
PTC** Cost Sharing **
6.3% of Income 73% Plan AV
Between 250-300% FPL?
Yes No
PTC** Cost Sharing **
8.05% of Income 70% Plan AV
Between 300-400% FPL
PTC** Cost Sharing**
9.5% of Income 70% Plan AV
At any FPL an Indian enrolled in a QHP is eligible for services without cost-sharing from Indian Health Services, Indian Tribes, Tribal
Organizations, or Urban Indian Organizations. This special cost-sharing must be provided without the individual having to go through
the determination for insurance eligibility programs.
Detailed Processes
13 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Citizenship found in federal hub to match attestation?
• Citizen • National • Lawfully Present • Native American
Yes No
14
Yes No
Exchange finds an
inconsistency
END
SSN verified by info in federal
hub?
Eligibility process continues
END
Information verified against information from electronic
sources (DHS) for lawful presence in US, individual
with no SSN and where SSN doesn’t match
Yes No
END
Check Citizenship/Verify SSN Check Citizenship
Eligibility process continues Exchange makes reasonable effort to identify
the inconsistency and notifies individual and
gives 90 days for application filer to provide
satisfactory documentation. Eligibility process
continues and if meets other eligibility criteria,
HIX provide non-Medicaid coverage during
this time.
END
Inconsistency resolved after
90 days?
If enrolled, Individual is
disenrolled
Yes No
Reasonably Compatible?
Start
Agency must verify Indian status and cannot accept self-attestation.
Self-Attestation
*9
Individual remains enrolled
Period can be extended if applicant is making good
faith effort to obtain additional documentation.
*10
The 90 day reasonable opportunity period does not apply to Medicaid. Individual is not enrolled in
Medicaid until the discrepancy is resolved.
Continued Medicaid requirement to provide emergency services to
individuals not eligible for full Medicaid due to their immigration status.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
*11
15
Approved Electronic Data
source available for
verification of incarceration?
Yes No
END
Check Incarceration Check Incarceration
Reasonably compatible?
END
Inconsistency resolved?
Exchange makes reasonable
effort to identify the
inconsistency
Eligibility process continues
Yes No
Eligibility process continues
Yes
Start
Self Attestation
*9
END END
Exchange makes reasonable effort to identify
the inconsistency and notifies individual and
gives 90 days for application filer to provide
satisfactory documentation. Eligibility process
continues and if meets other eligibility criteria,
HIX provide non-Medicaid coverage during
this time.
Inconsistency resolved after
90 days?
Individual is disenrolled, if
enrolled
Yes No
Individual remains enrolled
Resolution period can be extended if applicant is making good faith effort
to obtain additional documentation.
*12
The 90 day reasonable opportunity period does not
apply to Medicaid.
*10
Incarceration is not a factor of eligibility which needs to be verified for purposes of
determining Medicaid eligibility. It is generally prohibited for Medicaid to cover services while
individuals are incarcerated.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
No
*11
State Residency found in
federal hub?
Yes No
16
Yes No
Exchange finds an
inconsistency END
Residency verified?
Eligibility process continues
END
Adult: Where living &
intends to reside or is
seeking employment or
employed
Child <21: living in, or state
of residency of
parent/caretaker with whom
child resides
State can accept self-
attestation without further
review
Yes No
END
Check State Residency Check State Residency
Eligibility process continues.
Exchange makes reasonable effort to identify
the inconsistency and notifies individual and
gives 90 days for application filer to provide
satisfactory documentation. Eligibility process
continues and if meets other eligibility criteria,
HIX provide non-Medicaid coverage during
this time.
END
Inconsistency resolved after
90 days?
Eligibility Process Continues Eligibility process stops
Yes No
Data in another Electronic Source &
Compatible?
Start
Document that provides evidence of immigration status
may not be used alone to determine that individual is not
state resident.
Self Attestation
*9, 12
Resolution period can be extended if applicant is making
good faith effort to obtain additional documentation.
If attestation of residency is not reasonably compatible with other
information provided, the Exchange must examine information in data sources that are available to the Exchange and approved by HHS.
*10
The 90 day reasonable opportunity period does not apply to Medicaid. An individual is not enrolled in Medicaid
until the discrepancy is resolved.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
*11
17
Household Size Info via Fed
Data Hub - Filer?
Yes No
Verified by Requestor?
Yes No
Self-Attestation from
Requestor
Reasonably Compatible?
Yes No
Yes No
Use Self-Attested Household
Size
Requestor Provide
Paperwork
Received and Approved w/in
90 Days?
Not eligible for Continued
Determination Due to
Insufficient Data
END
Use Other Electronically
Found Household Size Use Manually Calculated
Size as Household Size
Start
Use data from Hub as
household size
Data Found via Other
Sources?
Yes
No
Sufficient Electronic Secured
Data Available?
No
END
END
END
END
Agency must accept self-attestation of pregnancy unless the State has information that is not
reasonably compatible with the attestation. States can require verification of pregnancy with
multiples for purposes of determining household size for Medicaid. *9
Basic rule for tax filers is that the household size consists of the
taxpayer and all tax dependents.
In Medicaid, a pregnant woman is considered a household of two (or more if carrying
multiples). States have the option to count the unborn children in determining the family size
of other members of a pregnant woman’s household for Medicaid eligibility purposes.
Calculate MAGI Household Size
P18
Determine Household Size Determine
Household Size
Yes
*14
*12
The Exchange must compute annual household income for the
family based on the number of dependents on the tax return.
Attestation must be verified with the tax filer.
*10
The 90 day reasonable opportunity period does not
apply to Medicaid. Individual is not enrolled in Medicaid until the discrepancy is resolved.
*13
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
Calculate MAGI Household Size P18
Is the individual a tax filer?
Yes No
18
No
END
The individual is a non filer
Yes
No
END
Yes
Start
Is the individual claimed as
a dependent?
The individual’s Household size is the tax filing household size
Household size consists of if living with the individual: (1) the individual’s spouse; (2) the individual’s qualifying children ; (3) if the individual is under 19 or 21 and a full time student the individual’s qualifying parents and siblings.
Is the individual: •Other than a spouse, biological, adopted or step child •Under 19 or under 21 & full time student & claimed by non-custodial parent • Living with both parents who will not file joint tax return
Married couples living together are included in the household of the
spouse regardless tax filing status.
If individual cannot substantiate that another individual is a tax
dependent for the year in which Medicaid coverage is sought,
non-filer rules apply.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
In Medicaid, unborn children are included in household size for pregnant
women. State has option to count unborn children in household size for
other household members. *14
19
Household Income Info via
Fed Data Hub - Filer?
Yes No
Verified by Requestor?
Yes No
Self-Attestation from
Requestor
Reasonably Compatible?
Yes No
Gather sum of income for household: Pay Stubs, Letters of employment
Medicaid count Lump Sum in month received. Grants/ Scholarships not counted (<138%* Only), AI/AN Income not counted
Attest that to an accurate projection of next benefit year income for non-Medicaid.
Yes No
Accept Self-Attested
Household Income without
further verification
Requestor Provide
Paperwork
Received and Approved w/in
90 Days?
Not eligible for Continued
Determination Due to
Insufficient Data or no
longer filer
END
Use Other Electronically
Found Household Income
Use Manually Calculated Income as Household
Income
Determine Household Income Start
Use Fed Hub Electronically
Found Household Income
Data Found via Other
Sources? Yes
No
Sufficient Electronic Secured
Data Available?
Yes No
END
END
END
END
Determine Household Income
Tax subsidy requires filing for continued receipt of benefits.
*9
*12
Must search to see if applicant has filed for unemployment benefits.
Attestation must be verified with the tax filer.
Higher Self-Attestation and
No eligibility impact? < 10% Lower and PTC?
If applicant’s income attestation is higher than reported and does not
impact eligibility OR is no more than 10% below, Exchange must accept
attestation without further verification.
*10
The 90 day reasonable opportunity period does not
apply to Medicaid. Individual is not enrolled in Medicaid until the discrepancy is resolved.
If Medicaid and No eligibility
impact?
*17
*18
Medicaid eligibility is based on current monthly income. Annual income must
be converted to monthly number . State option to use projected annual income for ongoing eligibility. Medicaid MAGI exceptions must be applied including :
• Deduct sources counted as income by IRS but not Medicaid (taxable scholarships, grants; AI/AN exceptions; Lump Sum Payments counted only in month received) •Exclude income of child or other tax dependent who files taxes but isn’t required to •Count Social Security Income that is tax exempt
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
*16
*18
Calculate FPL
Yes No
20
END
Start Option A
Perform Medicaid
Determination and Re-
Calculate FPL
Calculate FPL
Calculate FPL
States have the option of performing an Assessment via an Exchange and then a Determination through Medicaid (option
A) or a Determination through the Exchange (option B)
Assessed Above 100% FPL or 138%* FPL at State Option
Assessment = Determination for Exchange
*6
Assessed Above 138%* Assessed Above 100% FPL or
138%* FPL at State Option PL Yes No
Replace Assessed FPL with Medicaid Process Calculated
FPL
Medicaid Process FPL Determined
The State-Operated Federal PTC Partnership model may allow contracting with the Federal
Exchange to perform the Determination Assessment as shown
in Option A. Calculate FPL
END
Start Option B
Gather Additional State Medicaid Specific
Information from Applicant
In the event that the State has another entity perform an eligibility assessment,
the State can then collect additional, non-duplicative, information to determine Medicaid eligibility.
If a state selects the option that the Exchange will perform the eligibility
determination, no additional information can be collected at this
time from the applicant.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
State Decisions Needed
21 DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
22
1. Will the State use the CMS application or develop a state specific application? For the Non-MAGI application, will the State use the single streamlined application & supplemental forms or an alternative application?
2. A redetermination of eligibility must be made without requiring additional information from the individual when reliable information is available to the State to complete the renewal. What will be considered reliable information?
3. For Medicaid renewals, the State can extend the reconsideration period during which a new application is not required. Will the State offer a longer reconsideration period? The State may also implement a 90 day reconsideration period for reasons other than non-timely submission of renewal materials.
4. The State may replicate the MAGI redetermination process for non-MAGI Medicaid populations. Will the State implement these renewal procedures for non-MAGI?
5. The Exchange may automatically enroll qualified individuals at open enrollment in QHPs. Will this option be implemented?
6. The State may delegate Medicaid determinations to the Exchange or Medicaid may make an eligibility determination in addition to the Exchange’s initial assessment.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
State Decisions Needed (1 of 4)
23
7. The State can expand the definition of caretaker relative to include another relative based on blood, adoption or marriage, domestic partner or adult with whom the child is living and assumes primary responsibility.
8. In defining who is considered a dependent child for purposes of eligibility for the Medicaid Parent/Caretaker Relative Group, the State may eliminate the deprivation requirement. Dependent children can also be defined as either under 18 or 18 and full time student in secondary school or training if before age 19 child is expected to complete training.
9. Within the rules guidelines for upper and lower limits, State to define rules for what is considered reasonably compatible when self-attestation does not match electronic data. State to determine when self-attestation will be allowed without further verification through electronic data sources.
10. State to determine the reasonable time period for allowing individuals to provide verification documents for Medicaid eligibility determinations.
11. The 90 day grace period for providing documentation to resolve discrepancies may be extended when the applicant demonstrates a good faith effort has been made to obtain the required documentation. Will this option be utilized and under what circumstances?
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
State Decisions Needed (2 of 4)
24
12. State to define other electronic data sources (approved by HHS) that will be utilized in addition to those accessed through the Federal Data Hub.
13. For Medicaid eligibility, State may require verification of pregnancy with multiples for purposes of determining household size.
14. States have the option to count the unborn child(ren) in determining the family size of other members of a pregnant woman’s household for Medicaid eligibility purposes.
15. For purposes of determining household composition for Medicaid, State has option to count children as either under Age 19 or under Age 19 or in the case of full-time students, under 21.
16. If individual is found Medicaid ineligible due to lump sum payment, State may opt to reconsider eligibility in a subsequent month without requiring a new application.
17. For a tax dependent claimed by an individual other than a spouse or parent, the State has the option to count as income available cash support provided by the tax filer.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
State Decisions Needed (3 of 4)
25
18. For individuals determined Medicaid eligible under MAGI, states may elect to base ongoing financial eligibility on current monthly household income or projected annual income for the remainder of the calendar year. Thus, State needs to decide whether to use a point in time income or projected annual income in the Exchange. State can also opt to continue to account for reasonably predictable fluctuations in income for Medicaid determinations.
19. States to determine income standard for Medicaid consolidated groups within minimum and maximum parameters defined in federal regulation.
DRAFT - Eligibility Process Flows -Based on our Interpretation of 42 CFR Part 435 Subsection B & C and 45 CFR Part 155 Subsection D Published March 2012
