DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
Center for Medicaid and CHIP Services 
 
                SHO #13-008    
                Affordable Care Act #28 
 
 
November 29, 2013  
RE: New Flexibility: Using Account Transfer Flat Files 
to Enroll Individuals in Medicaid and CHIP 
 
Dear State Health Official:  
Dear State Medicaid Director:  
 
In order to facilitate timely enrollment in Medicaid and the Childrens Health Insurance Program 
(CHIP) in 2014, the Centers for Medicare & Medicaid Services (CMS) will permit states to 
enroll individuals in Medicaid and CHIP based on the account transfer (AT) flat files transmitted 
by CMS to states served by the Federally Facilitated Marketplace (FFM) for a transition period, 
through the exercise of waiver authority under section 1902(e)(14)(A) of the Social Security Act 
(the Act).  These flat files do not contain the full electronic account for the individual, but 
contain sufficient information to identify the individual and indicate the FFM determination or 
assessment of Medicaid or CHIP eligibility.  CMS has been sharing these AT flat files with 
states to help them anticipate their individual workload and customer service needs, in advance 
of full account transfers.  We plan to expand reporting through the AT flat file to include the 
additional information necessary to enroll individuals.  
 
The expanded AT flat file will contain sufficient information in order for states to complete 
enrollment and assign the individual to the appropriate Medicaid or CHIP group.  The file will 
include data elements such as: date of birth, social security number, eligibility category used for 
assessment or determination, and verification inconsistencies.  The file will identify individuals 
who have been assessed or determined eligible for Medicaid and CHIP on the basis of modified 
adjusted gross income (MAGI).  The file will also identify the individuals that cannot be enrolled 
through this process because they have an income or residency verification inconsistency, or 
because they have been referred on a non-MAGI basis.  
 
This new, transitional opportunity for states to enroll individuals assessed or determined eligible 
by the FFM, using the information provided through the AT flat files, will ensure that enrollment 
can be completed in a timely way without regard to temporary file transfer system issues at either 
the federal or state level.  It will also help states pace their workloads with respect to enrollment 
of residents who have applied through the FFM.     
 
This interim enrollment option is not intended to supplant the regular account transfer web 
service. Once the account transfer web service is operational between the federal government  Page 2  State Health Official and State Medicaid Director 
and the states, regular account processing should take place as soon as practicable.  This regular 
processing should include receipt and response protocols to allow the FFM to record state 
actions.   
 
Process for Using the AT Flat File  
 
In states that have elected to have the FFM make Medicaid/CHIP eligibility determinations 
(determination states), using the information from the AT flat file accelerates the opportunity for 
states to complete Medicaid or CHIP enrollment effective January 1, 2014 in a timely manner.   
Ordinarily, states would enroll such individuals upon receipt of the electronic account that 
contains the full eligibility file.  Use of the AT flat file for enrollment will protect beneficiaries 
by allowing them to be enrolled pending receipt of the full eligibility file and also allow states to 
spread out the workload of enrolling individuals.  To use this transitional process, states should 
request a waiver under section 1902(e)(14)(A) to authorize enrollment based on the AT flat file; 
the state will not have to take additional steps with respect to individuals enrolled through the flat 
files once the account transfer is received since the FFM has made the eligibility determination 
(other than acknowledgement of receipt and response to the FFM).  The simplified waiver 
request process is described below.  
 
In states that have elected to have the FFM make Medicaid/CHIP eligibility assessments 
(assessment states), the FFM is not authorized to make a final determination of eligibility based 
on MAGI.  The FFM review process, however, is just as robust as for a determination, except 
with respect to resolving inconsistences. As such, this option to enroll individuals assessed as 
eligible by the FFM will be extended to assessment states except, as described below, with 
respect to individuals for whom inconsistencies have been identified.  The enrollment period for 
individuals under this AT flat file method will be temporary; full account transfer and processing 
should still be completed to continue coverage beyond the temporary period. To exercise this 
option, states will need to request a waiver pursuant to section 1902(e)(14)(A) of the Act to 
authorize eligibility and enrollment based on the AT flat file.   
 
Under the waiver, determination and assessment states will have the authority to use this method 
for up to 90 days (with the possibility of extension for an additional period based on state 
circumstances).  Once the full account transfer is received from the FFM, and the state is able to 
act on those transfers, the state would process the new enrollments normally.   
 
Section 1902(e)(14)(A) of the Act, added by section 2002 of the Affordable Care Act, generally 
requires the use of the MAGI-based income methodology to determine Medicaid eligibility, and 
also allows for waivers as are necessary to ensure that states establish income and eligibility 
determination systems that protect beneficiaries.  Many states have requested, and received 
approval of, authority under section 1902(e)(14)(A) of the Act to implement the targeted 
enrollment strategies described in the May 17, 2013 letter to State Health Officials, available 
at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf.  We will use 
a similar submission and approval process for these waivers.  
 
States should use the template included in Appendix A of this letter to request a waiver.  Because 
this strategy does not involve section 1115 demonstration authority, these waivers are not subject  Page 3  State Health Official and State Medicaid Director 
to transparency or budget neutrality rules.  However, consultation with stakeholders is strongly 
encouraged.  Any state using this strategy, whether assessment or determination state, should 
update its mitigation plan on file with CMS.  CMS will also update the state profiles housed on 
the Medicaid Moving Forward page on Medicaid.gov for states that have requested and received 
the waiver authority.  Finally, to continue to protect personally identifiable information (PII), 
states will continue to follow the defined security protocols already in place for how they access, 
store and utilize the data in the AT flat file, consistent with signed privacy and security 
agreements. 
 
Treatment of Individuals 
 
For either determination or assessment states, only individuals who have been determined or 
assessed as eligible for Medicaid and CHIP by the FFM, including those in the reasonable 
opportunity period (as described in sections 1902(ee)(2)(C), 1903(x)(4), and 1137(d)(4)(A) of 
the Act), are candidates for the enrollment procedures described in this guidance.  These 
procedures are not appropriate and may not be used to enroll those who the FFM has not 
determined or assessed as Medicaid eligible, but have asked for a full Medicaid determination or 
who have been referred to the state by the FFM for processing based on non-MAGI criteria.  
Additionally, assessment states, which are responsible for resolving inconsistencies may not 
enroll individuals through the waiver process for whom there is an inconsistency between 
attested income and electronic data.  Regular processing of those applications will be required to 
ensure accurate determinations. States must apply their procedures equitably; they must treat 
similarly situated individuals similarly.   
 
For individuals whose eligibility is determined using the AT flat file, coverage could be effective 
as early as January 1, 2014.  In determination states, the individual remains eligible until their 
next regularly scheduled renewal or until a change in circumstances affects eligibility.  In 
assessment states, the waiver authority will permit enrollment for a temporary period (not to 
exceed 90 days, unless extended based on state circumstances). Once the account transfer is 
received and can be acted upon by the state, the state would proceed with a MAGI-based 
eligibility determination as soon as practicable, consistent with state and federal rules, including 
those which require states to respond to all transfers from the FFM with final eligibility 
determinations.    
 
If the state ultimately determines an individual enrolled pursuant to the waiver authority to be 
ineligible (under any eligibility category as per normal procedures), the state would then provide 
the appropriate advance notice to the enrollee to terminate that individuals Medicaid coverage.  
Individuals would have an opportunity to appeal the determination to terminate coverage, and 
states would have the option, but would not be required, to provide benefits pending the outcome 
of a fair hearing, in accordance with regulations at 42 CFR part 431 subpart E.     
 
It is important to note that states in which the FFM is doing an assessment rather than a 
determination will have the responsibility for effectuating a transfer of individuals into other 
coverage if they determine that the person is ultimately not Medicaid or CHIP eligible after the 
completion of this process, in accordance with regulations at 42 CFR 435.1200 and 457.350.  Page 4  State Health Official and State Medicaid Director 
This is no different than the steps an assessment state would normally take after a standard 
account transfer.   
As we move forward into 2014, we know that states are working hard to meet many 
implementation goals and timeframes. We anticipate that the strategy described in this letter will 
enable states to ensure that eligible individuals have timely access to Medicaid and CHIP 
coverage in a simple and streamlined manner and facilitate states ability to manage workloads 
associated with effectuating enrollment of eligible individuals who have applied through the 
FFM on a transitional basis.  CMS staff stands ready to assist states interested in using the AT 
flat file to facilitate enrollment of individuals in Medicaid and CHIP.  We will hold an all-state 
SOTA call in early December to review this new option with states.  Questions regarding this 
strategy may be directed to Anne Marie Costello at AnneMarie.Costello@cms.hhs.gov and 
Marielle Kress at Marielle.Kress@cms.hhs.gov or may be handled through the SOTA process. 
 
Sincerely,  
 
  /s/ 
 
Cindy Mann  
Director 
 cc:  
 
CMS Regional Administrators  
 
CMS Associate Regional Administrators  
Division of Medicaid and Childrens Health Operations 
 
Ron Smith  
Director of Legislative Affairs  
American Public Human Services Association  
 
Matt Salo  
President 
National Association of Medicaid Directors  
 
Joy Wilson  
Director, Health Committee  
National Conference of State Legislatures  
 
Melinda J. Becker 
Senior Legislative Associate 
Committee on Health and Homeland Security 
National Governors Association 
 
Debra Miller  
Director for Health Policy  
Council of State Governments   Page 5  State Health Official and State Medicaid Director 
 
 
Christopher Gould 
Director, Government Relations  
Association of State and Territorial Health Officials  
 
Alan R. Weil, J.D., M.P.P.  
Executive Director  
National Academy for State Health Policy  
 
 
     
APPENDIX A 
 
 
Mr. Eliot Fishman 
Director 
Children and Adults Health Programs Group 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, MS: S2-01-16 
Woodlawn, MD 21244 
 
Dear Mr. Fishman:   
         
In response to CMS guidance regarding the use of the information included in the Account 
Transfer (AT) flat file to enroll individuals in Medicaid and CHIP prior to receipt of the full 
eligibility file account transfer from the Federally Facilitated Marketplace (FFM), as a 
[ASSESSMENT/DETERMINATION] state, [STATE] requests a waiver under section 
1902(e)(14)(A) to use the data in the AT flat file to effectuate enrollment of eligible individuals 
who applied for coverage through the FFM but were determined or assessed to be 
Medicaid/CHIP eligible.   
 
We believe this practice will help individuals who have applied through the FFM but whose 
accounts have not yet been transferred to be enrolled in Medicaid or CHIP in a timely manner.    
 
[STATE] requests the authority to effectuate enrollments in Medicaid and CHIP using the AT 
flat files for 90 days.    
 
For additional information or questions regarding our request please, contact XX at XX. 
 
Sincerely, 
 
 
 
State Medicaid/CHIP Director 
 
Cc:    Anne Marie Costello, Deputy Director, Children and Adults Health Programs Group 
Margaret Barry, Policy Advisor, Children and Adults Health Programs Group