Wednesday, July 10, 2013

CMS Finalizes Rule Implementing Medicaid Eligibility and Enrollment Provisions

The Centers for Medicare & Medicaid Services on Friday, July 5, issued a final rule implementing provisions of the Patient Protection and Affordable Care Act (ACA) regarding eligibility and enrollment for Medicaid and Children’s Health Insurance Program (CHIP), and the coordination with the health insurance exchanges (also known as Health Insurance Marketplaces). The final rule also updates and simplifies existing Medicaid premium and cost sharing requirements.

The final rule does not include a number of provisions from the January proposed rule, such as continuous eligibility for children and pregnant women, certified application counselors in exchanges, and the coordination of individual market exchanges and Small Business Health Options Program (SHOP) exchanges. CMS expects to finalize these provisions in future rulemaking.

Highlights of the proposed rule follow.

Presumptive Eligibility: States have long used presumptive eligibility to temporarily enroll pregnant women and children in Medicaid or CHIP. Thirty-two states have adopted presumptive eligibility for pregnant women, and 17 states have adopted presumptive eligibility for children. The ACA created a new requirement for states to specifically allow hospitals to make presumptive eligibility determinations, even if a state had not previously established a presumptive eligibility program. The final rule would implement this requirement by allowing hospitals to self-elect to make presumptive eligibility determinations.

A presumptive eligibility program allows providers, on behalf of their patients, to begin the enrollment process based on some key pieces of information at the point of service. The final rule outlines the five basic criteria that a hospital must meet to be authorized to make presumptive eligibility determinations. Specifically, a hospital must: (1) participate as a Medicaid provider; (2) notify the state Medicaid agency of its decision to make presumptive eligibility determinations; (3) agree to make determinations consistent with state policies and procedures; (4) assist individuals in completing and submitting the full application, at the state’s discretion; and (5) not be disqualified by the agency.

Against the AHA’s urging, CMS will allow states to limit the populations for which a qualified hospital can make presumptive eligibility determinations to children, pregnant women, parents and caretaker relatives, disabled adults or adults eligible through an 1115 Waiver. In addition, the AHA requested in its comments to CMS that it develop uniform federal standards for hospitals making presumptive eligibility determinations so that hospitals serving patients from multiple states would have a consistent set of standards. CMS, at this time, chose not develop a federal standard.

Certified Application Counselors for Medicaid and CHIP: The final rule recognizes that many state Medicaid and CHIP programs have established relationships with providers, such as hospitals, to assist individuals seeking health coverage. In this capacity, many hospitals have served as “application assisters,” promoting health coverage enrollment for low-income populations and often providing much-needed language translation assistance. The final rule outlines a certification process to provide the training and skills needed to access confidential data and meet confidentiality requirements, as well as enable certified application counselors to track and monitor applications. The AHA supports CMS’s efforts to recognize the services of community-based providers and hospitals in providing application assistance through a certification process.

The final rule does not include provisions from the proposed rule regarding certified application counselors for exchanges nor provisions regarding accessibility for disabled or persons with limited English proficiency. CMS notes that these provisions will be addressed in future rulemaking.

Essential Health Benefits in the Medicaid Alternative Benefit Plan (ABP): The ACA requires that the Medicaid ABP be modified to include the new eligibility group of low-income adults, also known as the “expansion population.” The ACA further requires that the ABP be modified to include the essential health benefit (EHB) requirements identified by the Department of Health and Human Services (HHS), including mental health and prescription drug coverage.

The state Medicaid agency has the responsibility to ensure that the ABP for the expansion population meets the ACA’s EHB requirements. The final rule includes a two-step process that states must follow. First, a state must determine whether the ABP meets the criteria for a benchmark option for EHB, as set by HHS. If so, the standards for both the APB and EHB will be met. If the benchmark option is not met, the state will proceed to the second stage – identifying one of the EHB base-benchmark options and supplementing the ABP until all EHB requirements are met. The final rule notes that CMS will allow states a transition period beyond Jan. 1, 2014 to come into compliance with aligning the ABP with the EHB requirements, as long as a state is making reasonable progress toward compliance.

States must comply with the federal mental health parity law, as well as comply with the EHB-required habilitative benefit. Habilitative services help individuals attain, retain or improve their skills and functioning. According to the final rule, states will be allowed to separately define habilitative services if the benefit is not covered in the ABP subject to CMS approval. The AHA supported allowing states flexibility in defining habilitative services.

Premium Assistance: The final rule clarifies that a state Medicaid program may purchase coverage in the individual market exchanges through premium assistance. States have long had the option to purchase coverage in the private market on behalf of Medicaid beneficiaries, but the final rule clarifies that premium assistance is available for the new adult coverage group.

The final rule notes that individuals receiving coverage through premium assistance are Medicaid beneficiaries and entitled to the full range of protections, including benefits and cost sharing protections. States needing additional flexibility are advised to explore 1115 demonstration waivers.

Verifying Premium Tax Credit Eligibility: The final rule clarifies that, when an individual applies for premium tax credit through the exchanges, the individual is responsible for providing the exchange with information as to whether he or she has access to employer sponsored coverage. This clarification answers questions raised by the recent decision to delay the ACA’s employer shared responsibility provisions requiring employers to offer their employees health insurance coverage and report such information to the exchange. Exchanges will rely on this self-reported information to determine an individual’s eligibility for premium tax credits.

Medicaid Cost Sharing: The final rule streamlines current Medicaid cost-sharing rules. With regard to inpatient cost-sharing, the final rule limits the maximum cost sharing for individuals at or below 100 percent of the Federal Poverty Level to $75. For those states with high maximum cost sharing amounts for inpatient services, the final rule allows states a transition period until July 1, 2017 to comply.

The final rule also clarifies language regarding a hospital’s statutory responsibility to inform an individual seeking treatment through the hospital’s emergency department (ED) that alternative sources of care in the community are available, and that, if the patient chooses to proceed with treatment, an ED cost-sharing amount would apply. The clarification allows hospitals to merely determine rather than ensure if the alternative source of care in the community can provide services in a timely manner. While imposing cost-sharing for non-emergency use of EDs is one strategy to reduce this costly service, it poses challenges for hospitals in that the collection of Medicaid cost-sharing amounts for non-emergency care in ED settings can prove difficult, leading to lack of payment and increases in bad debt. The AHA continues to encourage CMS oversight with regard to ED cost-sharing requirements.

Continuous Medicaid Eligibility: The proposed rule included several provisions that codified, in regulation, options for states to provide certain population groups with continuous Medicaid eligibility. Such groups included: hospitalized children that “age out” of the program during an inpatient hospital stay; pregnant women through the end of the post-partum period; newborns born to Medicaid-eligible mothers through the first 12 months of life; and children under age 19, regardless of changes in income or circumstances. The AHA supported these coverage provisions. None of these provisions was included in the final rule. It is expected that some or all of these provision will be included in future rulemaking.

Medicaid “Institutions for Mental Diseases” (IMD) Restrictions: The final rule clarified that, for the adult coverage group or “expansion population,” the IMD restriction applies. The IMD restriction is a payment restriction where Medicaid will not pay for the cost of inpatient care incurred when treating Medicaid beneficiaries ages 21-64 if they receive treatment in IMDs such as private psychiatric hospitals. These freestanding psychiatric hospitals play a vital role in ensuring access to community-based mental health care for those with serious mental illnesses. The AHA supported lifting the IMD payment restriction for mental health services provided to the Medicaid expansion population through the Alternative Benefit Plan.

If you have questions, please contact Molly Collins Offner, director of policy development, at (202) 626-2326.


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