DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
Center for Medicaid and CHIP Services
 
 
 May 22, 2012 
 
Medicaid/CHIP Affordable Care Act Implementation 
Answers to Frequently Asked Questions 
 
Eligibility Policy 
Q1:  Which eligibility groups were consolidated under the final rule?   
A:  The Medicaid eligibility final rule at 435.110, 435.116 and 435.118 set forth the 
mechanism for consolidating certain federal eligibility categories into four main groupings:  
adults, children, pregnant women and parents/caretaker relatives.  The table provided below lays 
out the consolidation of mandatory and optional eligibility groups (a version of this table was 
also included as part of the preamble to the proposed rule).  
  
Realignment of Medicaid Eligibility Groups 
 
BEFORE  AFTER 
  Affordable Care Act Final Rule 
Mandatory Medicaid  Parents/Caretaker  Pregnant  Children <19 
Eligibility Groups  Relatives  Women  (435.118) 
(Pre-Affordable Care Act)  (435.110)  (435.116) 
Low-Income Families -        
1902(a)(10)(A)(i)(I) and 1931       
Former AFDC - 435.110  X  X  X 
Qualified Pregnant Women &       
Children <19 -  X  X 
1902(a)(10)(A)(i)(III)  435.116  
Poverty-Level Related       
Pregnant Women & Infants -   X  X 
1902(a)(10)(A)(i)(IV)  No rule 
Poverty-Level Related       
Children Ages 1-5 -  X 
1902(a)(10)(A)(i)(VI)  No rule 
    Page 2 
Poverty-Level Related       
Children Ages 6-18 -  X 
1902(a)(10)(A)(i)(VII)  No 
rule  
Optional  Medicaid   Parents/Caretaker  Pregnant  Children <19 
Eligibility Groups  Relatives (435.110)  Women  (435.118) 
(Pre-Affordable Care Act)  (435.116) 
Families & Children Financially       
Eligible for AFDC -    X   
1902(a)(10)(A)(ii)(I)  435.210  
       
Families & children Who       
Would be Eligible for AFDC if    X  X 
Not Institutionalized - 
1902(a)(10)(A)(ii)(IV)  
435.211 
Poverty-Level Related       
Pregnant Women & Infants -  X  X 
1902(a)(10)(A)(ii)(IX)  No rule 
 
Q2:  Do States need to track people enrolled in the adult group who become pregnant?   
A:  States are not required to track the pregnant status of women enrolled through the new adult 
group.  Women who enroll in the adult group who later become pregnant will have the option of 
either staying enrolled in the adult group, or requesting that the State move them to a pregnancy-
related eligibility group.  This is most likely to occur if women need specific benefits that are not 
available under the adult group benchmark benefit package. 
 
Q3:  If a woman indicates on the application she is pregnant, do States need to enroll her as 
a pregnant woman if she is otherwise eligible for the adult group?  Would there be a need 
to track pregnancy if the benefits for both groups are the same? 
A:  If a woman indicates on the application that she is pregnant, she should be enrolled in 
Medicaid coverage as a pregnant woman.  The Affordable Care Act specifies that pregnant 
women are not eligible for the new adult group.  As mentioned above, if a woman enrolled in the 
adult group later becomes pregnant, she will have the option to stay enrolled in the adult group or 
request that the State move her to a pregnancy-related eligibility group.   
 
Q4: In 2014, will the eligibility groups for people with breast and cervical cancer and 
disabled workers continue to exist? 
A: Yes, the breast and cervical cancer group and the eligibility group for working disabled 
individuals will remain optional eligibility groups which States may elect.  The Affordable Care 
Act did not alter the financial or non-financial requirements or methodologies used to determine 
eligibility for these groups, both of which are exempt from the application of Modified Adjusted 
Gross Income (MAGI) methodology for determining income. 
  Page 3 
Q5: What happens to existing groups like 1931 and Transitional Medical Assistance 
(TMA)? 
A: Coverage under section 1931 of the Act was not repealed with the ACA and will remain in 
effect in 2014.  As noted in the table above, eligibility for parents and caretaker relatives under 
1931 is implemented at 435.110 of the regulations; eligibility for pregnant women under 
1931 is implemented at 435.116 and eligibility for children at 435.118.  TMA under section 
1925 of the Act will sunset on December 31, 2012, unless extended by Congress.  If Congress 
elects to extend section 1925 of the Act beyond December 31, 2013, States will need to provide 
TMA to eligible individuals as set forth in their approved State plans. Note that the 4-month 
extension for individuals losing eligibility under 1931of the Act due to increased earnings or 
hours of work (see sections 1902(e)(1)(A) and 1931(c)(2) of the Act), and the 4-month extension 
of eligibility for individuals losing eligibility due to increased spousal support (see section 
1931(c)(1) of the Act) do not have a sunset date and would therefore still apply in 2014 unless 
repealed by Congress.  The extension of eligibility for individuals losing coverage under 1931 
due to increased child support will no longer be relevant in 2014, as child support is not counted 
as income under MAGI-based methodologies. 
 
Q6: Can individuals with disabilities and other long-term care needs (who are not eligible 
in the mandatory group of SSI beneficiaries) be eligible for coverage under the new 
Medicaid expansion adult group in 2014? 
A: Yes. People with disabilities or who need long term care services and supports may qualify 
under the new adult group in 2014 if they meet the MAGI-based eligibility standards for that 
group.  In addition, under the final eligibility and enrollment rule, eligibility for the new adult 
group based on MAGI does not preclude eligibility for coverage under an optional group that 
might be otherwise excepted from MAGI methods.  Individuals with MAGI-based income up to 
133% of the federal poverty level who meet the criteria for the adult group but who need long-
term services and supports, can choose to enroll in an optional group that better meets their 
needs, and they can move from the adult group to the optional eligibility group at any time, if 
eligible.  Individuals found eligible for the new adult group based on MAGI, but who appear on 
the application to be potentially eligible for Medicaid on a basis other than MAGI, will be 
offered a more thorough eligibility determination so that they can have this option. 
 
Q7: What happens with the medically needy group in 2014 and what are the policy options 
to continue covering this group?  Is that group newly eligible with 100% federal match?   
A: States may continue to provide coverage to medically needy individuals in 2014, and indeed 
are required to offer such coverage with respect to children until the maintenance of effort 
requirement provision in 1902(gg) of the Act expires.  States have the option to discontinue 
coverage under medically needy groups for adults (e.g., disabled individuals with income above 
the standard for categorical eligibility) in 2014, subject to 1902(gg).  In States that continue to 
cover existing medically needy adult groups, adults who meet the categorical eligibility and 
resource requirements will have the ability to spend down to the medically needy income 
standard and receive the benefits covered for medically needy individuals in the State, or to 
enroll in the adult group (provided they meet the eligibility requirements for that group, 
including being under 65 and not eligible for Medicare).   
  Page 4 
 
Q8: What information will be included in the required verification plan?  Will CMS 
provide a model verification plan that can be used by States?  Will the verification plan be 
part of a States Medicaid State Plan?  Will CMS review each States verification plan?   
A: The final rule specifies that Medicaid and CHIP agencies will establish their verification 
policies and procedures in a verification plan.  This plan is not a required element of the 
Medicaid State plan but States suggested, and CMS agrees, that it will be helpful to have the 
each States eligibility verification process established in a written plan.  The verification plans 
will serve many purposes, including ensuring PERM reviews are mindful of the States 
verification policies and also for promoting coordination with the Exchange.  States verification 
plans will be public and available upon request, but we are not establishing a Federal approval 
process.  State verification policies must of course always be consistent with applicable Federal 
at 435.940  435.956 of the eligibility final rule. 
 
The verification plans will include information about the data sources the State will use to verify 
applicant information, define reasonable compatibility standards, and determine when self-
attestation will be accepted.  CMS will provide a verification plan template for States to use 
 
Q9: What are the eligibility factors for which States can/cannot accept self-attestation? 
A: Self-attestation is permitted for all factors of eligibility, except as required by law (i.e. 
citizenship and immigration status).  States must accept self-attestation of pregnancy, unless 
information provided is not reasonably compatible with other information in the States files.