Twenty-one of these states also cover lawfully residing children or pregnant women in CHIP. This means they must wait 5 years after receiving "qualified" immigration status before they can get Medicaid and CHIP coverage. These limits may present barriers to children receiving necessary dental and orthodontia care. Application of the timeliness standards at 435.912(c)(3) in this situation aligns with the proposed revision of current regulations at 435.916(a)(3)(iii), redesignated at proposed 435.916(b)(2)(iii), to apply the timeliness standards to redeterminations initiated during the 90-day reconsideration period afforded beneficiaries under current regulations to return renewal forms. Adding new paragraphs (c)(1)(i)(A)( 2) and ( If the agency requests documentation in accordance with this paragraph, the agency must provide the individual with at least 90 days from the date of the request to provide any necessary information requested and must allow the individual to submit such documentation through any of the modalities described in 435.907(a). All estimates are based on the projections from the President's FY 2023 Budget. PDF Coverage and Reimbursement of COVID-19 Vaccines, Vaccine - Medicaid Processes that provide greater flexibility, such as reduced documentation requests and more time for returning information, can reduce these barriers. Option 1: Selecting the EHB-benchmark plan that another State used for the 2017 plan year. Any action the State requires the individual to take prior to enrollment, such as payment of an enrollment fee or selection of a plan, should be described in the combined notice provided to the individual and the individual should be given adequate time to respond to prevent or minimize a gap in coverage. (f) http://policy.ssa.gov/poms.nsf/lnx/0501.130300. For purposes of paragraph (e)(1) of this section, an individual is considered ineligible for Medicaid if they are not eligible for any eligibility group covered by the agency that provides minimum essential coverage as defined at 435.4. We seek to streamline enrollment for individuals known to be Medicaid eligible, like current enrollees who are also eligible for but not enrolled in the MSPs. If the remaining countable income exceeds the MNIL, the individual will need to meet a spenddown; that is, the individual will need to reduce the amount of their income above the MNIL by the amount of their outstanding medical and remedial care expense liability, from bills the individual incurs during their current budget period, and, in some circumstances, previous to it (for example, under 42 CFR 435.831(f), bills incurred in previous budget periods that were not used to meet a spenddown because the individual had other bills that were sufficient to meet the spenddown in the previous budget periods may be used in the current budget period). We propose to revise and redesignate current 435.916(d) (related to promptly acting on changes in circumstances) to proposed 435.919(b) and (c). CMS does not automatically initiate Part B buy-in for SSI individuals who live in SSI criteria and 209(b) States; rather, States must initiate Part B buy-in once the SSI recipient has separately applied for and been determined eligible for the mandatory SSI or 209(b) group. Specifically, we propose at 435.919(g)(1) that States that obtain updated in-state mailing information from NCOA or managed care plans may treat such information as reliable, provided that the State conducts the following outreach. Apply for Medicaid and CHIP. The QDWI group is not included in this proposal, because the income limits of the QDWI group are significantly higher than LIS and there does not exist the flexibility to disregard resources that are available for the other MSPs. Promoting Enrollment and Retention of Eligible Individuals, 5. To facilitate the enrollment of SSI recipients into the QMB eligibility group we propose, consistent with section 1902(a)(4) of the Act to promote the proper and efficient administration of the Medicaid program, the January 28, 2021 Executive Order on Strengthening Medicaid and the Affordable Care Act, the April 5, 2022 Executive Order on Continuing to Strengthen Americans' Access to Affordable, Quality Health Coverage, and the December 13, 2021 We have learned through our experiences working with States and other stakeholders that certain policies continue to result in unnecessary administrative burden and create barriers to enrollment and retention of (i) If the agency elects to terminate or suspend coverage in accordance with this paragraph, the agency must send notice to the beneficiary's last known address or via electronic notification, in accordance with the beneficiary's election under 435.918 of this subpart, no later than the date of termination or suspension and provide notice of fair hearing rights in accordance with 42 CFR part 431 subpart E. (ii) If whereabouts of a beneficiary whose coverage was terminated or suspended in accordance with this paragraph become known within the beneficiary's eligibility period, as defined in 435.916(b), the agency. (b) (i) Consistent with paragraph (c)(1) of this section, the agency must provide beneficiaries with at least 30 days from the date the agency sends the notice to verify the accuracy of the new contact information. However, States that do not currently perform such electronic matches must develop that capacity if such match is available and would be effective in accordance with the standard set forth in 435.952(c)(2)(ii). Instead, the individual must separately apply for premium Part A at SSA using the conditional enrollment process. A combined notice must meet the general requirements described at 435.917(a), along with the more specific requirements at 435.917(b) (relating to required content) and 435.917(c) (relating to pursuing eligibility on a non-MAGI basis), except that information described in 435.917(b)(1)(iii) (relating to medically needy coverage) and 435.917(b)(1)(iv) (relating to covered benefits and services) may be included either in a combined notice issued by another insurance affordability program or in a supplemental notice provided by the agency. If a State found that an individual has income exceeding the income standard during the post-enrollment verification process, the State would take appropriate action consistent with regulations at 435.916(d) (redesignated and revised at proposed regulations at 435.919 in this rulemaking), including determining eligibility on other potential bases and, if not eligible on any basis, providing advance notice and fair hearing rights prior to terminating MSP coverage. These changes correspond with the changes proposed to the Medicaid regulations at 435.1200(e). (1) The State must limit any requests for additional information under this section to information relating to change in circumstances which may impact the enrollee's eligibility. Start Printed Page 54798 We also seek comment on whether all States have a Medicaid Enterprise We believe the changes proposed in this rule will further these program integrity efforts, and we will continue to work closely with States throughout implementation. A State may enter into an arrangement with the Exchange for the entity that determines eligibility for CHIP to make determinations of eligibility for advance payments of the premium tax credit and cost sharing reductions, consistent with 45 CFR 155.110(a)(2). require an in-person interview for MAGI-excepted applicants. 5. Individuals who are not eligible for premium-free Part A are not automatically enrolled in premium Part A and they must enroll in Part B prior to or at the same time as they enroll in Part A. Second, we estimated how many persons would enroll who receive Medicare Part A but have to pay a premium. If 17 or younger, use the form named If the agency cannot renew eligibility for beneficiaries in accordance with paragraph (b)(1) of this section, the agency . We seek comment on the feasibility of implementing a combined notice for Medicaid and CHIP eligibility determinations, as well a combined notice with determinations of BHP and insurance affordability programs available through the Exchanges, both in States using a fully integrated eligibility system or shared system and in States utilizing separate systems. CHIP is administered by states, according to federal requirements. The first opportunity individuals have to enroll in premium Part A is during their initial enrollment period (IEP). Ten States limit dental coverage to $500-$2,000 annually, and four States limit lifetime orthodontia coverage to $725-$1,250. Mass.gov is a registered service mark of the Commonwealth of Massachusetts. While documenting the amount of actual in-kind support and maintenance can be difficult for applicants, we do not believe it is common for applicants to attempt to rebut the one-third FBR presumption, and therefore, it is rare that applicants are faced with providing documentation of this type of income. We developed a regression using the percentage of LIS enrollees who were also enrolled as dual eligibles as the dependent variable, and used several policy factors as independent variables: State use of MIPPA applications; verification policies and procedures; grace period for providing verifications after initial denial; redetermination grace period; counting children towards income; income disregard; and asset disregard. 2023 Open Enrollment is over, but you may still be able to enroll in 2023 health insurance through a Special Enrollment Period. This beneficiary lives in a State that continues coverage through the end of the month in which an individual becomes ineligible. Regarding the technical amendments, first we propose to remove and definitions from the title of 435.1200(b), as definitions are currently included in 435.1200(a), and we propose to correct the spelling of programs in 435.1200(b)(3)(i). In addition, 435.907(d) prohibits States from requiring an in-person interview as part of the application process, when determining eligibility based on MAGI, whereas States are still permitted to (2016, May). For beneficiaries, we estimate a total savings of minus $96,140,628 ($72,105,471$24,035,157).12. of this proposed rule, we propose to establish time standards for States to promptly act on changes in circumstances and standards for acting on anticipated changes in circumstances in proposed 435.912(c)(5) and (6), and we cross reference to these proposed time standards in proposed 435.919(c)(2). 61. These provisions, included in the statute when it was first enacted in 1997, place certain limitations on the use of waiting periods, which were implicitly recognized at the time as one of the potential strategies states could use to fulfill the requirement at section 2102(b)(3)(C) of the Act to address substitution of coverage. This would mean that beneficiaries have 30 calendar days from the date a form is postmarked or, for beneficiaries who elected to receive electronic notices, the date the electronic is sent. Start Printed Page 54852 13. In aggregate, we estimate an annual savings of minus 2,800 hours (56 States 50 hr) and minus $134,803 ([(40 hr $46.14/hr) + (10 hr $56.16/hr)] 56 States) for processing fewer full applications. are overall standards for determining, renewing and redetermining eligibility in an efficient and timely manner across a pool of applicants or beneficiaries, and include standards for accuracy and consumer satisfaction, but do not include standards for an individual applicant's determination, renewal, or redetermination of eligibility. Section 1860D-14(a)(3)(C)(i) of the Act, added by section 116 of MIPPA, excludes in-kind support and maintenance as countable income for LIS determinations. Second, we propose a technical change to 435.1200(e)(1) to replace the reference to 435.916(d) with a reference to proposed 435.919 to reflect the re-designation of current 435.916(d) at 435.919 in this proposed rule. https://oig.hhs.gov/oas/reports/region4/41608047.pdf; Colorado Did Not Correctly Determine Medicaid Eligibility for Some Newly Enrolled Beneficiaries, Office of Inspector General, 2019. Time standards for redetermining eligibility. Second, based on this information available to the State agency, the State must attempt to contact the beneficiaries by both mail, as well as a modality other than mail, such as by phone, electronic notice, email, or text message, as permissible. We have received reports from advocates that obtaining documentation of a life insurance policy's cash surrender value is highly burdensome for applicants. who also meet certain resource criteria. Medicaid also does not permit annual or lifetime limits. Download the Options after Age 26: Health Insurance Information for Adult Disabled Dependents Fact Sheet. In aggregate, we estimate a one-time burden of 2,200 hours (11 States 200 hr) at a cost of $207,493 ([(50 hr $98.50/hr) + (150 hr $92.92/hr)] 11 States) for completing the necessary system changes. https://www.govinfo.gov/content/pkg/FR-1994-01-12/html/94-547.htm. As discussed above in section II.B.3 of the preamble, we seek comment for both Medicaid and CHIP on whether proposed 435.912(c)(4)(ii) (incorporated in CHIP through 457.340(d)) balances maximizing the completion of timely renewals prior to the end of an enrollee's eligibility period and providing States with sufficient time to complete redeterminations and provide notice for enrollees who return needed documentation or other information prior to the end of their eligibility period, but not by the date requested by the agency to ensure completion of a timely renewal. We propose to redesignate current 435.916(f) (related to determining eligibility on all bases and transmission of data pertaining to individuals no longer eligible for Medicaid) and 435.916(g) (relating to accessibility of renewal forms and notices) to proposed 435.916(d) and (e), respectively. First, individuals who are Medicaid eligible based on being age 65 or older or having blindness or a disability are more likely to live on a fixed income and, therefore, are more likely to remain financially eligible for coverage than the non-disabled beneficiaries under age 65 who qualify for Medicaid based on MAGI. 33 0 obj <> endobj For example, if a State projects the private rate for the services for an institutionalized individual, and the private rate for a particular month exceeds the individual's spenddown and the individual is consequently deemed Medicaid eligible on the first day of the month, the individual will not be charged the private rate for any of the services that month, but instead will be charged the Medicaid rate, as the provider would have to accept the Medicaid reimbursement rate for the Medicaid-covered services. Of that amount, we estimate that $60,280 million would be paid by the Federal government and $39,010 million would be paid by the States. (2) If you apply for Medicaid coverage to your state agency, youll also find out if your children qualify for CHIP. In paragraph (a), by removing the phrase case record facts to support the agency's decision on his application and adding in its place the phrase and beneficiary's case record the information and documentation described in 431.17(b)(1) of this subchapter; and. Staying covered: the importance of retaining health insurance for low-income families. renewal based on information available to the agency is not successful, this will result in termination at the individual's regular renewal because such beneficiaries will not receive a mailed notice or renewal form and will be unable to respond as required. We therefore propose at 435.919(f)(1)(ii) that the State must obtain and check the address on file with the plan for any individual enrolled in a managed care plan. In total for the ICRs related to 435.919 and 457.344 under OMB control number 0938-1147 (CMS-10410), and taking into account the 50 percent Federal contribution, we estimate a total State cost of $33,844,092 ($126,609 + $46,645 + $9,024,603 + $24,646,235).We estimate that current State policies on returned mail may have contributed to approximately 2.125 percent drop in enrollment. Using the analysis on SSI enrollees and coverage, this is a weighted average of an 18 percent increase in Medicare costs for those newly gaining Medicaid. RHCs are required to be staffed by physician assistants, nurse practitioners, or certified nurse midwives at least half of the time that the clinic is open. (2) Request additional information needed to determine eligibility and obtain a signature under penalty of perjury consistent with 435.907(e) and (f) of this chapter respectively as referenced in 457.330 if such information or signature is not available to the State or included in the information described in this paragraph (d). ICRs Regarding Eliminating Requirement to Apply for Other Benefits (435.608). We also are concerned that a longer reconsideration period for applicants would mean that a longer period of time will have elapsed between the date the applicant has attested to information provided on the application and the date a determination is ultimately made. Non-liquid resources. Finally, we propose to delete current paragraph (f)(3), which requires the State to determine or redetermine eligibility when the Medicaid agency returns a determination of ineligibility for an individual whom the separate CHIP agency screened as potentially Medicaid eligible, since under proposed 457.350(b) the CHIP agency will have completed a determination of eligibility for MAGI-based Medicaid and proposed 435.1200(c) would require the Medicaid agency to accept the determination of eligibility made by the separate CHIP agency. Proposed 435.1200(e)(1)(ii) would require that when the Medicaid agency determines an individual to be ineligible for both Medicaid and CHIP, the agency must determine potential eligibility for BHP if the State operates a BHP and if ineligible for BHP, the agency must determine potential eligibility for insurance affordability programs available through the Exchanges. Lock Changes reported by the enrollee. Section 457.810 is amended by revising paragraph (a) to read as follows: (a) In 2022, that is approximately $165 million. Barriers to coverage that are not permitted under any other insurance affordability programincluding lock-outs for individuals terminated due to non-payment of premiums, required periods of uninsurance prior to enrollment, and annual or lifetime caps on benefitsremain a State option in separate CHIPs. If the individual does not provide basic information about the policy and an authorization, under proposed 435.952(e)(4)(iv)(B), the State may require that the individual provide documentation of the cash surrender value. In total, we project that these provisions would increase Medicaid enrollment by 2.81 million by 2027, and would increase total Medicaid spending by $99,290 million from 2023 through 2027. Therefore, this new requirement would mean system changes for all 50 States and the District of Columbia, (altogether, 51 States). The Children's Health Insurance Program (CHIP) is a joint federal and state program that provides health coverage to uninsured children in families with incomes too high to qualify for Medicaid, but too low to afford private coverage. Kyle J. Caswell, Timothy A. Waidmann, The Urban Institute, June 2017: CMS finds this to be problematic for several reasons. In total, we estimate these provisions would increase enrollment by about 120,000 by 2027. In accordance with 435.406(a) and section 1137(d) of the Act, individuals must first make a declaration of U.S. citizenship or satisfactory immigration status in accordance with 435.406(a). In such cases, any functions performed by the separate CHIP agency would be solely administrative in nature, and not reflective of a delegation of authority to make Medicaid eligibility determinations. [85] These markup elements allow the user to see how the document follows the (c) An individual must not be required to provide additional information or documentation unless information needed by the agency in accordance with 435.948, 435.949, or 435.956 cannot be obtained electronically or information obtained electronically is not reasonably compatible, as provided in the verification plan described in 435.945(j), with information provided by or on behalf of the individual. (2) of minus $5,340,997 ($426,503 + $5,767,500). First, we propose to modify the title for proposed 457.350(d) to clarify that this provision applies to actions that States must take when determining an individual eligible for Medicaid based on MAGI, rather than actions the State must take for individuals found potentially eligibility for Medicaid. Each of these provisions could be more or less effective than we have assumed in developing these estimates, and for many of these provisions we have made assumptions about the impacts they would have. As discussed in section II.B.3. that agencies use to create their documents. Under the regulations, all States must first attempt to verify citizenship electronically using data from the SSA, and most States rely on a match through the Federal Data Services Hub (FDSH) for this data. Maryland Children's Health Insurance Program Medicaid Medicare Buy-In Program Long Term Care Medical Assistance Forms Maryland Children's Health Insurance Program (MCHP) uses Federal and State . All 51 States would need to make eligibility systems changes to deem an SSI individual in QMB once they are eligible for Medicare. The complexities of tracking waiting periods, sending notices to families, and requiring families to take additional steps to transition coverage likely result in children who are eligible for CHIP being unenrolled. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. (vii) For separate CHIPs that are not Statewide, if the address obtained from NCOA or the State's managed care plans are outside of the State's specific geographic area for its separate CHIP, the requirements of paragraphs (f)(1) through (3) of this section to verify out-of-state addresses are applicable. As noted above, waiting periods have never been allowed under Medicaid and are not permitted in the Exchanges, either. However, for an individual eligible under both the mandatory SSI and QMB groups, the State need only verify that the individual still receives SSI and is entitled to Medicare Part A in order to renew their eligibility in both groups. The State must establish eligibility and enrollment mechanisms and procedures to maximize coordination with the Exchange, Medicaid, and CHIP. https://www.medicaid.gov/federal-policy-guidance/downloads/cib11012021.pdf. First, States can expand their buy-in agreement with CMS under section 1818(g) of the Act to include enrollment and payment of Part A premiums for QMBs who do not have premium-free Part A. The analysis found a larger change in costs for those without any other coverage than those with supplemental coverage. Additionally, as described at proposed 435.907(d)(1)(ii), applicants must be permitted to provide additional information through any of the modes by which an application may be submitted at current 435.907(a). The State plan must provide that the records required under paragraph (b) of this section will be retained for the period when the applicant or beneficiary's case is active, plus a minimum of 3 years thereafter. A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. Premium lock-out periods, by design, require children or pregnant individuals to go without coverage for a specified period. We also make technical changes to current 435.916(d)(1)(ii), redesignated at proposed 435.919(e)(2), to use the term eligibility period rather than renewal period and to remove the reference to the 12-month eligibility period to align the length of the new eligibility period the State may begin for an individual consistent with the eligibility periods described in proposed 435.916(a). However, for individuals excepted from use of the MAGI-based methodologies, 435.916(b) of the current regulations permits States to conduct regularly-scheduled renewals more frequently (for example, every 6 months). Further, while individuals can enroll in Part A at any time of the year without regard for Medicare enrollment periods or late enrollment if the State pays their Part A premium under its buy-in agreement, this is not the case for individuals who are paying the premium themselves. We propose a conforming amendment to the introductory language in 435.911(c) to include a cross reference to proposed 435.919 to make clear that the terms of 435.911(c) apply also to individuals whose eligibility is being redetermined following a change in circumstances. Lawfully present immigrants are eligible for coverage through the Health Insurance Marketplace. In particular, one commenter stated that 80. In addition, section 112 of MIPPA amended section 1905(p)(1)(C) of the Act to increase the resource limit for the QMB, SLMB, and QI MSP eligibility groups to the same resource limit applied for full LIS established at section 1860D-14(a)(3) of the Act. The proposed 435.952(e)(4) changes will be submitted to OMB under control number 0938-0467 (CMS-R-74), regarding the collection of information for income verification.
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