CMS Issues Final Rule on Medicaid and Children’s Health Insurance Program Eligibility Provisions, Appeals, and Related Administrative Procedures


On July 5, 2013, CMS issued a final rule supplementing the Exchange final rule, reflecting new statutory eligibility provisions and implementing changes related to Medicaid and the Children’s Health Insurance Program (CHIP) authorized under the Affordable Care Act (ACA).  According to CMS, “[t]he intent of this final rule is to afford each state substantial discretion in the design and operation of the Exchange established by the state, with greater standardization provided where directed by the statute or where there are compelling practical, efficiency or consumer protection reasons.”  See final rule

Key provisions of the final rule include:

  • options for a coordinated appeals process between the Marketplace, Medicaid and CHIP;
  • the delegation of authority by state Medicaid agencies to the Marketplace to conduct Medicaid fair hearings provided certain standards are met;
  • a requirement that notices to applicants, enrollees and beneficiaries include accurate information regarding insurance affordability program eligibility;
  • a requirement that electronic notices from the Marketplace be available beginning October 1, 2013, and from state Medicaid and CHIP agencies by January 1, 2015;
  • guidance on the use and planning of Alternative Benefit Plans;
  • the creation of a set of rules for Medicaid premiums and cost-sharing requirements; 
  • a requirement that Medicaid and CHIP agencies accept a single simplified application and make timely eligibility determinations during the initial open enrollment period (October 1, 2013 and January 1, 2014) to help facilitate the transition to the new coverage available in 2014 (though CMS is currently considering whether a later effective date for the initial open enrollment period is appropriate);
  • details on the procedures for the Marketplace to verify individuals’ access to adequate employer-sponsored coverage, which would make an individual ineligible to receive advance payments of premium tax credit or cost-sharing reductions; and
  • policies related to the new ACA provision permitting hospitals and other populations to make presumptive eligibility determinations.

See Fact Sheet.

CMS intends to address proposed provisions regarding Exchange eligibility appeals in a future issuance.  The final rule will be published in the Federal Register on July 15, 2013.

Reporter, Katy Lucas, Atlanta, +1 404 572 2822,

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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