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July 12
​CMS Issues Additional Affordable Care Act Rules

On July 5, the Centers for Medicare and Medicaid Services (CMS) issued a final rule on certain eligibility and enrollment changes under the Affordable Care Act (ACA). The rule, which can be found here, is scheduled to be published in the Federal Register on July 15, and provides additional guidance on how the Exchange (or “Marketplace”), Medicaid, and the Children's Health Insurance Program (CHIP) will work.

The Medicaid law allows states to design benefit packages “benchmarked” to commercial products. The final rule requires these plans to provide the 10 categories of Essential Health Benefits (EHBs) required by the ACA. It also provides guidance on the design and use of these benefit plans (now called Alternative Benefit Plans or ABPs) and their coverage of EHBs for the new “childless adult” Medicaid expansion population. In an apparent response to NACo’s comments on the proposed rule, it applies the longstanding statutory prohibition on federal financial participation (FFP) for services provided to “inmates” to APBs.

The rule also permits hospitals to make presumptive eligibility determinations – temporary Medicaid coverage – whether or not the state has presumptive eligibility as a state plan option.  This provision may help county hospitals reduce uncompensated care costs and help connect uninsured individuals to appropriate coverage.

Additionally, the final rule provides options for a coordinated appeals process between the Marketplace, Medicaid and CHIP, and allows state Medicaid agencies to delegate the Medicaid fair hearings to the Marketplace, as long as certain conditions are met.

The rule requires that notices to applicants, enrollees and beneficiaries must include clear and accurate information about eligibility for all insurance affordability programs (including Medicaid, CHIP, and help pay for health insurance coverage through the Marketplace) and requires that electronic notices will be available from the Marketplace on Oct. 1, 2013, and from state Medicaid agencies by Jan. 1, 2015.  

The rule permits states to establish higher cost sharing for prescription drugs, for non-emergency use of the emergency department and consolidates maximum allowable cost-sharing levels.  It also establishes one set of rules for all Medicaid premiums and cost sharing while leaving limits in place for the lowest income beneficiaries.  

The final rule establishes that Medicaid and CHIP agencies will begin accepting the single streamlined application during the initial open enrollment period between Oct. 1, 2013 and Jan. 1, 2014.


Contact: Paul Beddoe 202.942.9234


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