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
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
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 firstname.lastname@example.org