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Initiatives

Covering Kids & Families

Supporting Families

Child Care/Early Education

Southern Business Leadership Council

Carolina Nutrition Alliance

EPIC

2004 Chartbook of Major Indicators

 

The Burden of Proof:

How Much is Too Much for Child Health Coverage?

Additional Issues

Medicaid versus CHIP

Question 1
Are there any differences between federal Medicaid and CHIP verification requirements?
Only one. Unlike Medicaid, there is no requirement under CHIP for income and resource verification under IEVS.

Question 2
Does HCFA expect CHIP verification procedures to differ from the verification procedures for other Medicaid coverage groups?

Outside of verification that is required under federal law and regulations, it is up to the state to establish verification requirements for CHIP and Medicaid. To the extent they can be made the same, it would facilitate the application process in situations where a joint application is being used.

Random Verification Checks

Question
Can eligibility be granted based on statements in the application with random checks used to verify? If so, what is the minimum standard for random checks?

Yes. Self-declaration can be used for both CHIP and Medicaid with random checks. States must comply with the federal verification requirements that are discussed in response to earlier questions.

There is no minimum standard for random checks. It is up to the state to set a standard it considers reasonable.

Insurance Verification

Question
What are the minimum requirements for verification of insurance status?
For Medicaid, under IEVS the state is required to obtain information from various agencies, not only for purposes of verifying income and resources for Medicaid eligibility but also for verifying the correct amount of Medicaid payments. IEVS data matches may disclose potential legally liable third parties, which states must follow up on unless the eligibility case file includes information about the potential legally liable third party. HCFA also has issued guidelines (Section 3904 of the State Medicaid Manual) about obtaining health insurance information from the applicant that may be useful in identifying legally liable third party resources.

For CHIP, there are no verification requirements. However, states are expected to apply and monitor the crowd-out policies in their approved Title XXI plans.

Alien Status of CHIP Applicants

Question
How can a CHIP program that is not Medicaid verify alien status?

The state should use the same verification process it uses for Medicaid.

Continuous Eligibility

Question 1
For continuous eligibility, is certification of any information (age, income, etc.) required during the period of continuous eligibility?

No.

Question 2
Instead of annual reviews, why not allow reviews to be based on income of the family and extend it to 24-month or 36-month reviews? Why not allow extended Medicaid certification periods for categorically needy families?

For Medicaid, this is not allowed because reviews at least annually are required by regulation (but not the law) with respect to circumstances that may change. Also, except for continuous eligibility, the regulations require a prompt review when the Medicaid agency receives information about changes in a recipient’s circumstances that may affect his/her eligibility.

For CHIP, the frequency of review is up to the state to determine.

Regulation Clarification

Question
What is HCFA’s position on simplified eligibility/verification in view of regulations at 42 CFR 431.17 (b), which require case records to contain information on facts essential to determination of initial and continuing eligibility, and 42 CFR 435.913, whereby the agency must include in each applicant’s record facts supporting the agency’s eligibility decision?

HCFA’s position is that these regulations do not impose an obligation to verify under Medicaid. Since the application is signed under penalty of perjury, unless independent documentation or verification is required by federal law, regulations or guidelines, the requirement to have facts to support the eligibility determination may be satisfied by information based on a self-declaration of the applicant.

These regulations do not apply to CHIP.

Paternity Establishment/Assignment of Rights

Question
Does assignment of rights and cooperation with paternity establishment apply to children receiving coverage under CHIP? Under Medicaid?

These requirements do not apply to CHIP. For Medicaid, they do apply, except that the requirement to cooperate in establishing paternity and in obtaining medical support and payments does not apply to poverty-level pregnant women and persons who the state determines have good cause to refuse to cooperate.

Also, for Medicaid, children (including infants) cannot be denied or terminated due to the refusal of a parent or another legally able person to assign rights or cooperate in establishing paternity or obtaining medical support and payments.

HCFA is giving states flexibility to obtain information on non-custodial parents at any time during the application process. This means that the information does not have to be collected in the application itself as long as it is obtained in the application process. The last step in the application process is the notification of the eligibility determination. HCFA will issue a letter on this requirement in the coming months.

Social Security Number

Question
If a parent fails to supply a valid Social Security number for himself, can the child be denied eligibility for Medicaid?

Only applicants for and recipients of Medicaid benefits must supply this information. States are expressly prohibited from requiring the Social Security number of a parent or family member as a condition of a child’s eligibility. A Social Security number is required only for the child applying for Medicaid benefits. And for non-Medicaid CHIP programs, the provision of a Social Security number is optional. However, voluntary disclosure by the parent may facilitate income verification and expedite determination of the child’s eligibility.

Immigration Status

Question
Can a citizen child applying for Medicaid be denied because his or her parents are not citizens?

The citizenship or immigration status of non-applicant parents or other household members is irrelevant to a child’s Medicaid eligibility, and states may not require that parents provide this information about themselves. For children who are citizens applying for Medicaid or a separate state CHIP, states currently may establish citizenship on the basis of self-declaration. Children applying for either program and who are qualified aliens must present documentation of their immigration status, which states must verify using systems established for that purpose. (See HCFA letter dated September 10, 1998, in Appendix C.)

Under Medicaid, with the exception of obtaining documentation of immigration status for qualified alien applicants and the applicant’s Social Security numbers, states can determine their own documentation requirements, including self-declaration of income and assets.

Quality Control Concerns

Question
Quality control errors remain a big concern for states. Does HCFA plan to ease or eliminate the threat of Medicaid Eligibility Quality Control (MEQC) errors in Family Medicaid?

Medicaid eligibility quality control cannot be eliminated because it is a requirement of federal law. However, HCFA has given states considerable flexibility, within the parameters of the law, to implement the quality control process. In lieu of the traditional review of a case sample, states may carry out pilot projects designed to focus the state’s quality control efforts on areas where there may be problems. States also have the option to conduct alternative MEQC projects as part of an approved section 1115 waiver. States with approved pilot projects or section 1115 waivers are assigned an error rate which is the rate for their last full year under the regular system.

HCFA is aware of quality control concerns as states seek to simplify their application and enrollment processes for enrolling children into Medicaid. It is worth noting though that the national quality control error rate has been below the 3% tolerance for over a decade. We believe that as long as states maintain prudent administrative control over their Medicaid programs, there is little likelihood that states will be held disallowance liable. However, HCFA will continue to review the quality control implications of Medicaid eligibility application and enrollment simplification and will issue additional guidance, if appropriate.

Confidentiality

Question
Is confidentiality a concern in coordinating verification across programs?

Yes, it is a concern because confidentiality requirements vary from program to program. Some programs have strict disclosure requirements. For example, under Medicaid, disclosure of information about a Medicaid applicant or recipient must be for a purpose directly connected with the administration of the program.

Remote Eligibility Determination

Question
To facilitate more enrollment, why not allow remote eligibility determination sites for CHIP and Medicaid? What about letting entities other than the Department for Social Insurance and SSI determine eligibility?

For Medicaid, the law requires the determination of Medicaid eligibility to be made by state merit system employees. (The law allows states to contract with the Social Security Administration to determine Medicaid eligibility for aged, blind or disabled individuals.) Except for Medicaid outstationing, federal Medicaid funds may not be used for non-public employees to take applications and perform other initial application processing activities that precede the determination of eligibility. Under Medicaid outstationing, non-public employees, such as provider employees and private contractor employees, are permitted to perform initial application processing activities at federally qualified health centers, disproportionate share hospitals and other outstation locations where individuals go to receive services. Therefore, private entities are not permitted to operate the Medicaid process from application and eligibility determination to enrollment. However, within the parameters of the law noted above, states have flexibility to allow remote eligibility determination sites for Medicaid.

For CHIP, who performs application, eligibility determination and enrollment activities and how they are done is left to the state to determine.

Applying for Children

Question
Is a parent the only person legally able to file a child’s Medicaid application?

No. According to Regulation 42CFR435.907, "the agency must require a written application (either) from the applicant, an authorized representative, or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant." Therefore, someone other than a parent is permitted to initiate a Medicaid application on behalf of a child.