[42] As noted previously, when a determination of eligibility is completed after the end date of a beneficiary's eligibility period, current 435.930(b) requires the agency to continue furnishing Medicaid to the individual while the determination of eligibility is pending. 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. Because 10 States (about 20 percent of all States) do not have asset tests and do not require documentation to complete an eligibility determination or redetermination at the State Medicaid agency, we expect the savings from the self-attestation proposals would only apply to approximately 8.4 million individuals (80 percent of 11 million applications/renewals[84] First, as described in section II.B.1. Under 42 CFR 435.952(c)(1), income information obtained through an electronic data match shall be considered reasonably compatible with income information provided by or on behalf of an individual if both are either above or at or below the applicable income standard or other relevant income threshold. The Georgetown University Center for Children and Families estimated that 4.4 million children were uninsured in 2019, an increase from 2016 of 726,000 uninsured children. We considered allowing States, which have not yet transitioned their enrollee records into an electronic format, to continue to maintain a paper-based record keeping system. The projection of expenses can have the effect of accelerating eligibility. You can apply for or re-enroll in Medicaid or CHIP any time of year. We estimate that the provisions in 435.911(e) would save an Eligibility Interviewer 25 minutes (0.42 hr = 25 min/60 min) per eligibility determination at $46.14/hr for the 360,000 new LIS applicants from reduced paperwork to review because of the proposed self-attestation requirements and reduced verification work due to considering the leads data as verified. Under 406.20, many individuals who are not eligible for premium-free Part A may still enroll in Part A by applying for benefits at SSA and paying a premium (premium Part A). Despite the importance of the MSPs, a 2017 study conducted for MACPAC estimated that only about half of eligible individuals enrolled in Medicare were also enrolled in the MSPs. The general requirements for coordination are described at 435.1200(b). Finally, we make a conforming amendment to 431.213(d), which currently cross references 431.231(d), to instead reference 435.919(f). States receive an enhanced FMAP for administering their CHIP programs, ranging from 65 to 83 percent. There may also be different costs per enrollee than we have assumed herethose gaining coverage altogether or keeping coverage for longer durations of time may have different costs than those who were already assumed to be enrolled in the program. 2. In addition, we believe this proposal promotes equity across enrolled populations since non-MAGI beneficiaries, whose income tends to be more stable, would no longer be subject to more frequent requests to return renewal forms or provide documentation to verify continued eligibility than other beneficiaries. Mathematica Policy Research, funded by the David & Lucile Packard Foundation. Sometimes these services are also called "Rosie D." services. Health & Social Services MassHealth In Massachusetts, Medicaid and the Children's Health Insurance Program (CHIP) are combined into one program called MassHealth. We believe in-person interview requirements create a barrier for eligible individuals to obtain and maintain coverage without yielding any additional information than can be obtained through other modalities, particularly for individuals without access to reliable transportation or a consistent schedule. Individuals whose financial eligibility is determined using MAGI-based methodologies would not be required to apply for other benefits that would not count as income. Group payer States similarly can approve eligibility for individuals under the QMB eligibility group if SSA has determined them conditionally eligible for premium Part A, through a process known as conditional enrollment. The conditional enrollment process enables low-income individuals to apply at SSA for premium Part A on the condition that they will only be enrolled in Part A if the State determines they are eligible for the QMB group. But there may be. Start Printed Page 54852 Children whose health insurance covers the cost of vaccinations are not eligible for VFC vaccines, even when a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plans deductible had not been met. Current 435.912(c)(2) requires that, in establishing their timeliness and performance standards, States must account for the capabilities and cost of available systems and technology, the general availability of electronic data matching and ease of connections to authoritative sources of information to determine and verify eligibility, the demonstrated performance and timeliness experience of other State Medicaid, CHIP and other insurance affordability programs, and the needs of individuals, including their preferred mode of application submission and the relative complexity of adjudicating their eligibility. resources, which it defines as cash, financial accounts, and other financial instruments that can be converted to cash within 20 workdays. Ibid. The State BHP agency must fulfill the requirements of 42 CFR 435.1200(d), (e)(1)(ii), and (e)(3) and, if applicable, paragraph (c) of this section for BHP eligible individuals. A combined notice, discussed later in this section, may mitigate some risk of a coverage gap by notifying the individual about the CHIP enrollment fee or premium requirement at the same time advance notice of Medicaid termination is issued, providing some additional time for families to make the required CHIP payment before Medicaid coverage ends. https://oig.hhs.gov/oas/reports/region5/51700008.pdf. We estimate that 25 percent of States with a separate CHIP (40 States 0.25 = 10) are already using combined notices and would see no additional burden from this provision. Health Plan Required Documents & Deadlines | HealthCare.gov In 2022, that is approximately $165 million. of burden for the State to no longer review and adjudicate QMB applications from SSI recipients. We also estimate that it would save each State 50 hours to process full applications annually for beneficiaries who would no longer lose coverage and later reenroll. c. Redesignating paragraph (c)(3) as paragraph (c)(2); and. Section 406.21 is amended by adding paragraph (c)(5) to read as follows: (5) If an individual resides in a State that pays premium hospital insurance for Qualified Medicare Beneficiaries under 406.32(g) and enrolls or reenrolls during a general enrollment period after January 1, 2023, QMB coverage is effective the month entitlement begins (if the individual is determined eligible for QMB before the month following the month of enrollment), or a month later than the month entitlement begins (if the individual is determined eligible for QMB the month entitlement begins or later). This would include maintaining the current language in 600.330(a) and revising paragraphs (b), (c), (e), and (h) of 435.1200 to require the Medicaid agency to amend its agreement with the BHP agency to seamlessly transition eligibility between programs, to accept determinations of Medicaid eligibility made by the BHP agency, to make determinations of BHP eligibility, and to provide for the issuance of a combined Medicaid and BHP eligibility notice. Youll have at least 90 days from the date of your eligibility notice (usually the date you completed your application) to resolve the health insurance issue before your plan could end or change. Other eligibility criteria which may be applicable to determining eligibility for CHIP, which are not relevant in a Medicaid determination, include enrollment in other insurance coverage and access to State employee health insurance. KHN, November 9, 2019, Return to Sender: A Single Undeliverable Letter Can Mean Losing Medicaid. Available at (See section II.A.1. Proposed 435.912(b)(5) would require the establishment of specific standards for redeterminations of eligibility at the time of an anticipated change in circumstances in accordance with proposed 435.919(b)(3). Facilitate Enrollment Through Medicare Part D Low-Income Subsidy Leads Data (435.4, 435.601, 435.911, and 435.952), 2. These regulatory changes were issued by CMS in a November 2016 final rule titled, Medicaid and Children's Health Insurance Programs: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP (81 FR 86453, November 30, 2016) (referred to hereafter as the 2016 eligibility and enrollment final rule). As described at section 1860D-14(a)(3)(D) of the Act, the full-subsidy LIS resource limit is three times the SSI resource limit, adjusted annually based on changes to the Consumer Price Index. We estimate that under proposed 435.952(e)(1) through (e)(4), these 8.4 million individuals would see a reduction from 4 hours to 2 hours, for a savings of 2 hours per individual, to complete an application/renewal in all 41 States. We propose to revise 435.914(a) to apply to both applicant and beneficiary case records and to provide that the records maintained in each individual's case record include all those described in 431.17(b)(1), as revised in this proposed rule. 38. We seek comment on whether an effective date of 30 days following publication would be appropriate when combined with a later date for compliance for most provisions. For A locked padlock Medicaid also does not permit annual or lifetime limits. As discussed in sections II.B.2 of this proposed rule, we propose to revise and redesignate paragraphs (c) and (d) of current 435.916, related to changes in circumstances, to a new 435.919 that is devoted specifically to State and enrollees' responsibilities for acting on changes in circumstances. Several regulatory requirements, currently codified in subpart J of part 435, establish parameters to ensure that applications for coverage are not unduly burdensome and that new applicants receive a timely determination of eligibility. McCrae, Additionally, if a State attempts to contact the beneficiary to verify a new in-state address received from USPS and the individual does not respond, many States continue to use the original address in the beneficiary's case record. 16. We also seek comment on whether all States have a Medicaid Enterprise Start Printed Page 54811. (iv)(A) When an individual must provide documentation of the cash surrender value of a life insurance policy, the agency must assist the individual with obtaining this information and documentation by requesting that the individual provide The agency must redetermine eligibility within the time standards described in 435.912(c)(5) and (6), except in unusual circumstances, such as those described in 435.912(e); States must document the reason for delay in the individual's case record. Taking into account the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings would be minus $761,310. The income and resource requirements for coverage under the MSPs, and the benefits to which eligible individuals are entitled, are set forth at sections 1905(p)(1) and 1902(a)(10)(E) of the Act. Note: It is NOT recommended that you submit the ACA-3 application by mail as it may take a very long time to process. The agency may provide Medicaid to individuals under age 21 (or, at State option, under age 20, 19, or 18) or to one or more reasonable classifications of individuals under age 21 who meet the requirements described in any clause of section 1902(a)(10)(A)(ii) of the Act and implementing regulations in this subpart, if any. The following proposed CHIP State plan changes will be submitted to OMB for review under control number 0938-1147 (CMS-10410). We invite comment to identify any other types of services that individuals may receive on a constant and predictable basis, and for which a State could project, with a degree of relative certainty, consistent costs for an individual over the course of a prospective budget period. When a beneficiary no longer meets the eligibility requirements for the eligibility group under which they have been receiving coverage, the State must determine eligibility on all bases before terminating eligibility. Similar to the explanation provided for institutional expenses in the preamble to the 1994 rule, the projection of expenses for noninstitutional services is limited to those that are reasonably certain to be received by the individual, since only the amounts for which the individual is ultimately liable can be used to reduce income. Taking into account the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings would be minus $254,278. Those programs require applicants and recipients to accept other cash benefits which are available to them; see: section 407(b)(2) of the Act and 45 CFR 233.20(a)(3)(ix) regarding AFDC; and section 1611(e)(2) of the Act and 20 CFR 416.230 and 416.1330 regarding SSI. Actual underlying economic and public health conditions may differ than what we assume here. [51] However, beneficiary advocates raised concerns that these simplifications have not been afforded to Medicaid beneficiaries excepted from use of MAGI-based methodologies, which is particularly problematic given that individuals over age 65 and those who are eligible based on blindness or a disability are likely to have more stable eligibility. (i) The end of the beneficiary's eligibility period, in the case of a beneficiary whose eligibility can be renewed based on information available to the agency as described at 435.916(b)(1) or in the case of a beneficiary whose renewal requires additional information and who returns a renewal form 25 or more calendar days prior to the end of the eligibility period described in 435.916(a); (ii) The end of the month following the end of the beneficiary's eligibility period, in the case of a beneficiary whose eligibility is being redetermined on the basis for which the beneficiary has been receiving Medicaid (the applicable modified adjusted gross income standard described in 435.911(b)(1) and (2) or another basis) and who returns a renewal form less than 25 calendar days prior to the end of the beneficiary's eligibility period; and, (iii) The following time periods, in the case of a beneficiary who is determined ineligible on the basis for which they are currently receiving Medicaid and for whom the agency is considering eligibility on another basis. Additionally, stakeholders report that burdensome documentation requirements substantially impede eligible individuals from enrolling in the MSPs.[10]. Available at The same may be true of individuals who have significant expenses related to high-cost drugs that treat a chronic condition. States will be required to continue monitoring efforts to prevent substitution of coverage in accordance with section 2012(b)(3)(c) of the Act. rendition of the daily Federal Register on FederalRegister.gov does not We estimate that it would take all 40 States with a separate CHIP an average of 42 hours each to review any policy differences between their Medicaid and CHIP programs and make any necessary administrative actions to permit coordination of enrollment, such as a delegation of eligibility determinations or alignment of financial eligibility requirements between the two programs approximately. First, the analysis found that Medicare enrollees without other coverage had an average of $13,693 in costs, of which $2,399 was paid out of pocket (18 percent). In aggregate, we estimate this amendment would save beneficiaries in all States minus 547,034 hours (273,517 beneficiaries 2 hr) and minus $15,322,422 (547,034 hr $28.01/hr). period, one State has a 2-month waiting period, and one State has a one month waiting period. However, we believe this proposed rule will lead to more eligible individuals gaining access to coverage and maintaining their coverage across all States. 983 F.3d 246, 254 (6th Cir. An RHC is a clinic located in a Health Professional Shortage Area, a Medically Underserved Area, or a Governor-Designated Shortage Area. This data includes information on the individual's address, income, resources and household size that SSA has verified. 14009, 86 FR 7793. L. 111-152, enacted on March 30, 2010), together referred to as the Affordable Care Act (ACA). 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). Timeliness standards to furnishing additional assistance may not terminate the beneficiary's coverage or take other adverse action if the individual does not respond to the request for information. edition of the Federal Register. For individuals, we estimate that the amendments proposed under 435.407 would save each applicant 1 hour at $28.01/hr plus an average of $10 in miscellaneous costs [($4.50 postage for small package or $1.75/page for faxing) + $4 roundtrip bus ride (from home to printing/copying place to post office and back home) + $0.13/page for printing/copying], to no longer need to gather and submit paper documentation of citizenship. Therefore, to avoid possible erroneous grants of eligibility, we determined that the use of the Medicaid reimbursement rate in the projection of expenses was more appropriate. These changes call into question the appropriateness of waiting periods as a tool to address substitution of coverage. We believe this is an important update that would ensure that beneficiaries can easily report information that supports continued enrollment in Medicaid, such as updating contact information or reporting an in-state address change, even if the information would not constitute a change in circumstances that affects eligibility. A combined eligibility notice is defined at current 435.4 as an eligibility notice that informs an individual or multiple family members of a household of eligibility for each of the insurance affordability programs, for which a determination or denial of eligibility was made, as well as any right to request a fair hearing or appeal related to the determination made for each program. For purposes of this section. We seek comment on this proposal at 435.916(a)(1) to align the frequency of renewals for all beneficiaries, except as noted below. In some states, CHIP covers pregnant women. Permitting projection of such noninstitutional services would reduce some of the complexity that both State agencies and individuals seeking coverage of home and community-based services (HCBS) currently experience and reduce institutional bias. Section 1902(a)(19) of the Act requires that the Medicaid State plan include safeguards to ensure that eligibility is determined in a manner that is consistent with the simplicity of administration and the best interests of beneficiaries. as well as the record retention policy applied to managed care organizations under 438.3(u). Start Printed Page 54775 For individuals excepted from the mandatory use of MAGI-based methodologies, 435.601 generally This limitation continues to apply to all individuals excepted from mandatory application of MAGI-based methods under section 1902(e)(14)(D) of the Act, implemented at 435.603(j). In general, we have historically estimated that reductions in out of pocket costs would increase total spending by $0.60 to $1.30 for every $1.00 reduction in out of pocket costs. Section 457.65 is amended by revising paragraph (d) to read as follows: (d) Indeed, as noted in section II.A.1. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. This prototype edition of the 87. (1) Prior to making a determination of ineligibility, the agency must consider all bases of eligibility, consistent with 435.911. https://ccf.georgetown.edu/wp-content/uploads/2020/10/ACS-Uninsured-Kids-2020_10-06-edit-3.pdf. Box 8016, Baltimore, MD 21244-8016. 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). Proposed 457.340(f)(1)(ii) and (iii) would restate the requirements currently described in paragraph (f)(1)that is, at proposed 457.340(f)(1)(ii) to provide a combined notice to individuals transferred between the State and another insurance affordability program to the maximum extent feasible; and at proposed 457.340(f)(1)(iii) to require a combined notice for multiple members of the same household to the maximum extent feasible. Start Printed Page 54810 Consistent with the section II.E.2 of the preamble, we are proposing that CHIP adopt the substance of proposed 435.919 as 457.344 with some exceptions. If additional information from the beneficiary is needed, we propose at 435.912(c)(5)(ii) that States have through the end of the month that occurs 60 calendar days from the date the State receives information indicating a change in circumstances that may impact eligibility to make a redetermination of eligibility. Medicare Rights Center, February 2011. . In aggregate, we estimate an annual savings of minus 33,000 hours (44,000 applicants 0.75 hr) and $1,522,620 (33,000 hr $46.14/hr). When developing the coordination requirements currently published at 435.1200, 457.348 and 457.350, and 600.330, and 45 CFR 155.302, we recommended, but did not require States to utilize a shared eligibility system or service for all insurance affordability programs. We estimate that it would In aggregate, we estimate an annual savings of minus 151,200 hours (360,000 applicants 0.42 hr) and minus $6,976,368 (151,200 hr $46.14/hr). Proposed 435.919(e) includes the requirements in 435.916(d)(1)(i) and (ii) of current regulation (relating to the limitation on requests for information to necessary information and the circumstances under which States may begin a new eligibility period, which is the period of time between application and renewal or regularly scheduled renewals, following a change in circumstances). If you got Form 1095-B or 1095-C, don't include it with your tax return. Such practices fall short of States' statutory obligation to treat receipt of leads data as an application and to evaluate individuals' eligibility using the leads data. To revise 457.350(b) to require States to determine an applicant's eligibility for MAGI Medicaid and to determine potential eligibility for non-MAGI Medicaid, BHP, or insurance affordability programs available through the Exchanges for individuals who are not eligible for MAGI-based Medicaid. Describe eligibility, benefits , and administration of Medicaid Define eligibility, benefits, and administration of the Children's Health Insurance Program (CHIP) Summarize implications of the Affordable Care Act on Medicaid and CHIP Target Audience This module is designed for presentation to trainers and other information intermediaries. Start Printed Page 54808 The new results may change your current insurance eligibility and costs. Therefore, the requirement under proposed 435.911(e)(6) is in addition to the requirement to determine the individual's eligibility for an MSP. Available at We request comment on the challenges a State may face in seamlessly transitioning eligibility from another program, as well as strategies to mitigate those challenges. Of those 200 hours, we estimate it would take a Database and Network Administrator and Architect 50 hours at $98.50/hr and a Computer Programmer 150 hours at $92.92/hr. We made a final assumption that 60 percent of individuals would have enrolled in Marketplace coverage, and the remaining 40 percent would have either received other coverage or become uninsured. MassHealth members may be able to get doctors visits, prescription drugs, hospital stays, and many other important services. It is not an official legal edition of the Federal Proposed 435.1200(h)(1)(ii) would maintain the requirement in current 435.1200(h)(1) that, to the maximum extent feasible, a combined eligibility notice be issued in all other cases (that is, situations not described at proposed 435.1200(h)(1)(i)), consistent with current regulations. Current 457.350(h) (redesignated at proposed 457.350(i)) describes procedures for waiting lists, enrollment caps, and closed enrollment; we propose only a technical change to this section to update the cross-reference to reflect other changes proposed in this section. Retrieved from (2000). We do not propose to make any changes to 435.1200(d) in this proposed rule. to the agency by the United States Postal Service (USPS), the agency, (1) Must check the following sources for updated mailing address and other contact information. https://www.govinfo.gov/content/pkg/FR-1994-01-12/html/94-547.htm. rate.14 Of those 40 hours, we estimate it would take a Procurement Clerk 10 hours at $43.20/hr and a Management Analyst 30 hours at $96.66/hr. [D]enial of the recommended medical treatment means certain death for the minor, whereas continuation of such treatment offers him substantial hope for life. As such, under 435.912, States have 45 days to make an MSP eligibility determination based on the LIS data. https://oig.hhs.gov/oas/reports/region5/51800026.pdf; Start Printed Page 54800 Federal Data Services Hub), or 435.956 (relating to non-financial eligibility requirements), some have interpreted this requirement not to apply to verification of resources. We anticipate it would take an eligibility worker about 10 minutes (0.167 hr) to review a life insurance document and that this savings would affect 3 percent of applicants and beneficiaries or individuals (66,000 individuals = 11,000,000 individuals 0.03 0.2) across 10 States. http://policy.ssa.gov/poms.nsf/lnx/0501.130300. daily Federal Register on FederalRegister.gov will remain an unofficial Specifically, we propose to reinterpret the meaning of such income and resources as are, as determined in accordance with standards prescribed by the Secretary, available to the applicant or recipient in section 1902(a)(17)(B) of the Act to encompass only the actual income and resources within the applicant's or beneficiary's immediate control, but not to encompass such income and resources that might be available if such individuals applied for, and were found eligible for, other benefits. Subsequent to this rule, the majority (23 of 36) of States elected to eliminate their CHIP waiting period. The limited exception to application of true MAGI-based methodologies described in 435.603 of the regulations to medically needy individuals under 435.831(b)(1)(ii) stems from section 1902(a)(17)(D) of the Act. One study found that individuals who experienced interruptions in coverage had higher hospitalization rates for conditions, such as asthma and diabetes, that could have been managed in outpatient settings with consistent access to treatment.
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