Medicaid And CHIP In 2014: A Seamless Path To Affordable .
Medicaid and CHIP in 2014:A Seamless Path to AffordableCoverageSeniors and Individuals with Disabilities in theNew World of MAGICenter for Medicaid and CHIP ServicesApril 26, 2012
Whose Eligibility is Based onMAGI?MAGIMAGI-ExceptedAdultsAnyone for whom agency not required tomake income determination (e.g., SSI, federalfoster care or adoption assistance recipients)ParentsIndividuals eligible on the basis of being aged,blind or disabledChildrenIndividuals with long-term care needsPregnant womenIndividuals eligible as medically needyEligibility for Medicare cost sharing assistance2
MAGI-Exception for 65 Under the Final Rule Exception applies when age (65 ) is a condition ofeligibility. Current methods apply when determining eligibilityfor group covering individuals age 65 and older. MAGI methods applied in determining eligibility of acaretaker relative under 42 CFR 435.110 regardlessof the age of the caretaker relative.3
Eligibility on MAGI-ExceptedBasis Eligibility for mandatory eligibility group based onMAGI does not preclude eligibility for optionaleligibility group excepted from MAGI methods (e.g.,for disabled individuals, LTC needs). For example, disabled adults with MAGI-based income ator below 133% FPL who meet criteria for new adult groupcan be determined eligible for an enroll in optional groupfor disabled.4
Eligibility for Individuals NeedingLong-Term Care Services &Supports Adults with MAGI-based income at or below133% FPL, who meet criteria for adult group, butwho need LTC services not provided under adultgroup, can enroll in an optional eligibility groupthat better meets their needs.5
MAGI Screen If individual meets criteria for eligibility based onMAGI, must be promptly enrolled. Agency must pursue eligibility on MAGI-exceptedbasis if: Individual indicates potential for eligibility on otherbasis on single streamlined application; Individual submits application designed for MAGIexcepted eligibility; Individual requests such determination; Agency otherwise has information indicating suchpotential eligibility.6
MAGI-Screen (con’t) If the agency has information indicating potentialeligibility on another basis or at the individual’srequest, it must request additional information neededto make determination on MAGI-excepted basis. Individual is not required to provide information needed byagency to complete eligibility determination on MAGIexcepted basis. Enrollment based on MAGI proceeds pendingcompletion of the MAGI-excepted determination.7
MAGI-Screen (con’t) If agency approves eligibility on MAGI-exceptedbasis, individual must be enrolled; eligibility based onMAGI discontinued. If not eligible on MAGI-excepted basis or cannotcomplete determination (e.g., all information neededis not provided), individual remains eligible in MAGIbased group.8
Individual Choice Individual can choose to pursue or not to pursueeligibility on MAGI-excepted basis. Good information for informed choice is key. Once determined eligible on MAGI-excepted basis,individual is no longer eligible on basis of MAGI andcannot choose to remain in MAGI-based group. At next renewal individual can again exercisechoice through renewal process. If circumstances change, individual may move backinto adult group.9
John Jones John is a single 25-year old living on his own He has some medical conditions, but he is able to hold down apart-time job, and earns 1,000 per month. He submits the single streamlined application online andindicates his need for supportive services. The State has a HCBS waiver program which could potentiallymeet John’s needs.10
John JonesEligibility based on MAGI John’s Medicaid MAGI household John Household income 1,000/mo. 110% FPL – 5% FPL 105% FPL John is eligible for Medicaid under the adult groupbased on MAGI.11
John JonesEligibility on MAGI-Excepted Basis Because John has indicated a need for specializedservices which may be covered under the State’swaiver program, agency needs to requestadditional information from John to determine hiseligibility for that program. The agency will need to provide John with theinformation he needs to decide whether tocomplete the MAGI-excepted determination. Pending completion of the determination ofeligibility for the waiver program, John will remainenrolled through the adult group.12
John JonesEligibility on MAGI-Excepted Basis If John is determined eligible for the waiverprogram, he must enroll in that program. If John does not provide all information needed todetermine eligibility for the waiver program or theState determines he is not eligible, he will remainin the adult group.13
Individuals not eligiblebased on MAGI Agency must pursue eligibility on MAGI-exceptedbasis if: Potential for eligibility on other basis indicated onsingle streamlined application; Individual submits application designed for MAGIexcepted eligibility; Individual requests such determination; Agency otherwise has information indicating suchpotential eligibility.14
Scope of Policy Policy applies to all MAGI-excepted bases ofeligibility: Based on disability, blindnessLong-term care needsBreast and cervical cancerMedically needyDoes not apply to Medicare Savings Programeligibles15
“Reverse” MAGI Screen Individuals submitting alternative applicationfor MAGI-excepted populations must be ableto promptly enroll based on MAGI if eligible onsuch basis pending lengthier MAGI-excepteddetermination.16
Coordination with Exchanges Individuals not Medicaid eligible based on MAGI must beevaluated for potential eligibility for other insuranceaffordability programs and electronic account transmitted asappropriate. Agency must simultaneously pursue eligibility on MAGIexcepted basis if: Potential for eligibility on other basis indicated on single streamlinedapplication; Individual submits application designed for MAGI-excepted eligibility; Individual requests such determination; Agency otherwise has information indicating such potential eligibility. Same treatment for individuals submitting application toExchange.17
Smith FamilyMAGI Methods in Mixed Households Sally is married to John, who may be disabled. They have one child, Henry, age 6. Sally works and earns 1,500 per month. John is self-employed and works out of his home, earning 1,000 per month. They have no other income and no oneis eligible for Medicare. The applicable MAGI standard for adults is 133% FPL andfor children is 250% FPL. The State has a buy-in program for disabled individualswith income under 250% FPL. Sally completes the online application.18
Smith FamilyEligibility Based on MAGI Sally’s Medicaid MAGI household Sally John Henry John’s Medicaid MAGI household Sally John Henry Henry’s Medicaid MAGI household Sally John Henry Household income for each person 2,500/mo. 162%FPL – 5% FPL 157% FPL Henry is eligible for Medicaid based on MAGI; Sally andJohn are not.19
Smith FamilyEligibility on MAGI-Excepted Basis Sally does not indicate on the application that either Sallyor Henry may be disabled, that either has high medicalexpenses or that either needs long term care services.She does indicate that John may be disabled. The agency does not need to evaluate eligibility based ona MAGI-excepted basis for Sally or Henry, butappropriate information and notice will be provided sothat they can request such determination. The agency must evaluate John for eligibility for the buyin program for working disabled.20
Smith FamilyEligibility on MAGI-Excepted Basis The agency will collect additional information from Johnneeded to determine eligibility based on disability. It will apply the SSI-based methods to determine John’sincome and resources, including any optional disregardsadopted by the State, to determine John’s income for purposesof the buy-in program. Determination of eligibility for John based on disability doesnot affect the Medicaid MAGI households used for Sally orHenry. Sally and John will be evaluated by Exchange for APTC andCSR and can enroll if eligible, even as Medicaid agencydetermines John’s eligibility for the buy-in program.21
Next Webinar: Thursday, May 10th 3-4:30pm ESTEligibility & Enrollment Wrap-UpMore information on the final visions/Eligibility.htmlWebinar ty-and-Enrollment-Final-Rule-Webinars.html22
Apr 26, 2012 · Eligibility on MAGI-Excepted Basis Eligibility for mandatory eligibility group based on MAGI does not preclude eligibility for optional eligibility group excepted from MAGI methods (e.g., for disabled individuals, LTC needs). For example, disabled adults with MAGI-based income at or below 133% F
CHIP agency in order to verify their income, and their application may be suspended (no Medicaid or CHIP benefits) until they do so. Their state Medicaid or CHIP agency will inform them of what information to provide. The number of people in their household; Household composition and family size are important to calculate MAGI and
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