DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
CMCS Informational Bulletin 
DATE:  September 29, 2016 
FROM:  Vikki Wachino 
Director, Center for Medicaid and CHIP Services 
SUBJECT:     Enhancing Enrollment of Individuals Transitioning from Medicaid or CHIP to 
Marketplace Coverage 
Since the passage of the Affordable Care Act (ACA), states have made substantial progress in 
enrolling and retaining eligible individuals in Medicaid and the Childrens Health Insurance 
Program (CHIP).  A key aspect of continuing this progress is making sure that individuals who 
have either lost Medicaid or CHIP coverage or were determined ineligible upon application are 
able to transition to other sources of coverage and financial assistance, if applicable, as 
seamlessly as possible. Over the past three years of operation of the Federally-Facilitated 
Marketplace (FFM), we have learned through data analysis that there is more potential to enroll 
in Marketplace coverage individuals who are determined not or no longer eligible for Medicaid 
or CHIP and who have been transferred to the FFM via account transfer. This potential can be 
realized through a number of enhancements to the account transfer process. This CMCS 
Informational Bulletin (CIB) highlights the ways states served by the FFM can help to facilitate 
enrollment in Marketplace coverage for people transferred to the FFM when denied 
Medicaid/CHIP eligibility by the state Medicaid/CHIP agency. This CIB also provides 
information that may be useful for State-based Marketplaces working to improve their eligibility 
and enrollment coordination processes with state Medicaid/CHIP agencies. 
In addition, this CIB highlights ways states can make enhancements to the application and 
collection of data to help with successful enrollment. First, individuals are more likely to seek 
enrollment through the Marketplace if they have sufficient information to understand what will 
happen once the state has transferred their account to the Marketplace. Providing additional 
information to individuals found ineligible for Medicaid/CHIP regarding the transfer of their 
application from the state to the Marketplace will help to facilitate seamless coverage transitions. 
Second, enhancing the types of outreach, including the use of email outreach, to this population 
is essential to increasing the percentage of individuals who enroll in Marketplace coverage after 
being found ineligible for Medicaid or CHIP. Again, while this CIB focuses on transfers to the 
FFM, these improvements may be relevant to some State-based Marketplaces as well 
Adequate information and targeted outreach efforts are especially important for young adults  a 
group with historically high rates of uninsurance. When children become young adults, many 
lose eligibility for Medicaid or CHIP, or drop off of their parents coverage. Consistent with this, 
prior to the implementation of the Marketplaces and other ACA coverage provisions in 2014, 19 
year-olds were nearly 8 percentage points more likely to be uninsured than 18 year-olds. Recent   
 
CMCS Informational Bulletin  Page 2  
 
 
Census data show that, by 2015, that gap had shrunk to about 5 percentage points.1 Nonetheless, 
the remaining disparities show the potential to further reduce uninsured rates by smoothing 
coverage transitions for young adults. Our own data indicate that young adults also account for a 
large proportion of the accounts transferred from states to the FFM.  Improving the likelihood of 
seamless transitions between insurance affordability programs will help to ensure that young 
adults continue to receive the benefits of health coverage into adulthood. As such, this 
informational bulletin outlines the following strategies states should employ to expand the 
opportunities for increased enrollment through the Marketplace:  
 
  Improve eligibility determination notice language for individuals found ineligible for 
Medicaid/CHIP so that they are aware that the Medicaid/CHIP agency will be 
transferring their application to the FFM, and that the FFM will be sending them a notice 
with information on applying for coverage and financial assistance through the 
Marketplace; 
  Revise the manner by which states collect email addresses on the single streamlined 
application; and 
  Gather information from multiple trusted data sources to populate the individuals 
application and transmit all information the state has on an individual in the account 
transfer to the FFM, regardless of the minimum technical requirements for such account 
transfers. 
 
Improve Eligibility Determination Notice Language 
 
As described in the CMCS Informational Bulletin Coordination of Eligibility and Enrollment 
between Medicaid, CHIP and the Federally Facilitated Marketplace (FFM or Marketplace) 
issued on July 25, 2016, Medicaid and CHIP agencies are required to transfer the electronic 
accounts, for both applicants and beneficiaries, to the Marketplace when they are determined 
ineligible for Medicaid and CHIP. To ensure that individuals found ineligible for Medicaid or 
CHIP understand what will happen once the state has transferred the individuals account to the 
FFM, states should ensure their eligibility determination notices include language that explains 
the transfer process and next steps for completing an application at the FFM. Outreach to 
individuals whose accounts have been transferred to the Marketplace will be most effective if 
those individuals are educated about the future communication from an entity other than the 
state. Effective notice language lets an individual know their information has been sent to the 
Marketplace, that they will be receiving a letter from the Marketplace informing them that an 
application has been started for them, and informs them of their ability to start a new application 
at the FFM, which could result in a faster path to coverage. In addition, notices should provide 
information about what will happen once an individual completes an application at the 
Marketplace, as well as Marketplace contact information.  
 
Through the Expanding Coverage Learning Collaborative, with input from state Medicaid and 
CHIP agencies and consumer advocates, CMS has developed model account transfer notice 
                                                 
1 https://www.census.gov/content/dam/Census/newsroom/press-kits/2016/20160913_iphi_slides_plot_points.pdf   
 
CMCS Informational Bulletin  Page 3  
 
 
language for use by Medicaid and CHIP programs.  To demonstrate how the account transfer 
language can be used, we have inserted the language in a model Medicaid denial notice (see 
Attachment A).  The key account transfer messages are highlighted in the model denial notice.  
In late October, the Learning Collaborative will host a webinar on the account transfer process 
from the consumers perspective and tools to effectively communicate eligibility determinations, 
including how states can use and tailor the model notice language.  Details on the Learning 
Collaborative meeting will be provided to all FFM states.   
 
Revise Single Streamlined and Alternative Applications to More Easily Collect Email Addresses  
 
Another approach to help ensure that individuals who are denied Medicaid/CHIP eligibility are 
able to enroll in Marketplace coverage is to enhance existing outreach to these individuals 
through multiple avenues, including by email. Through three years of experience at the FFM, it 
has become evident that email outreach is a highly effective practice that should be expanded, 
especially to reach out to individuals being transferred from states to the FFM, to ensure more 
seamless transitions of coverage. Currently, the minority of accounts transferred from states to 
the FFM include email addresses, which results in the Marketplaces reliance on paper outreach 
notices. As email increasingly becomes a primary form of communication, it is important that 
states and CMS take steps to increase the likelihood that individuals provide email addresses on 
their applications, so that their email addresses can be provided to the FFM as part of the account 
transfer.  
 
In developing their single streamlined and alternative applications, most states followed the 
model paper single streamlined application which currently collects emails through a two-part 
conditional question. Individuals are asked whether they would like to get information about 
their application by email. Those who respond yes to this question are prompted to provide an 
email address. Asking the question in this format limits the number of individuals who provide 
email addresses to those who also want to receive information about their application by email.  
 
In order to increase the likelihood that applicants provide email addresses, states can revise how 
they collect email addresses on their applications. CMS recommends that states eliminate the 
two-part conditional question and ask all individuals for email addresses in an optional field 
within the contact information section of the application, similar to how phone numbers are 
collected. This practice is strongly recommended for both FFM and SBM states as outreach 
through email should be enhanced in all states, regardless of Marketplace type. Similar changes 
will be made to the model paper application in the near future. States can begin making these 
changes now, and the costs associated with these changes are eligible for the 90 percent 
enhanced match.  
 
Enhancing Robustness of Data Included in the Account Transfer 
 
If a state Medicaid/CHIP agency determines an individual is not eligible for Medicaid or CHIP, the 
agency must promptly assess the individuals potential eligibility for other insurance affordability 
programs and transfer the individuals electronic account to the appropriate program, per the   
 
CMCS Informational Bulletin  Page 4  
 
 
requirements described in 42 CFR 435.1200 and 457.350. The account must include all 
information collected and generated by the state regarding the individuals Medicaid or CHIP 
eligibility.  States should transmit all information the state has on an individual in the account 
transfer to the Marketplace, regardless of the minimum technical requirements for such account 
transfers. 
 
States can enhance the information sent to the FFM and further streamline the enrollment process for 
individuals transitioning to the Marketplace from Medicaid or CHIP by providing in the account 
transfer any contact information known to its system, even if the information does not originate from 
the initial application. For example, many individuals apply for Medicaid or CHIP using a paper 
application, but create online accounts after enrollment. Individuals may provide additional contact 
information, such as email addresses, as part of the state online account creation process. Encouraging 
account creation and the provision of email addresses also benefits consumers by moving away from 
paper notices that rely upon individuals to open their mail. States should incorporate the information 
provided through the account creation process in addition to the information provided through the 
application process in order to fully populate an individuals information sent by the state in the 
account transfer to the FFM. The ability to effectively contact individuals once their account is 
transferred to the FFM is critical to improving the likelihood that eligible individuals successfully 
enroll in coverage through the Marketplace.  
 
Additional Resources 
 
CMS will continue to work with states to ensure transitions to the FFM for individuals found 
ineligible for Medicaid and CHIP are as seamless as possible. For additional information, please 
contact your state SOTA lead or Judith Cash, Director, Division of Eligibility and Enrollment, 
Children and Adults Health Programs Group, at judith.cash@cms.hhs.gov or 410-786-4473. 
  Attachment A 
 
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You can get this letter in another language, in large print, or in another way  o
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thats best for you. Call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX).  s
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Usted puede obtener esta carta en otro idioma, con letras mas grandes,   V
o en otro formato que sea mas conveniente para usted. Llamenos al   
 
1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX).  e
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Mary Smith  Health coverage application date: May 1, 2016  i
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123 Any Street  Letter date: May 5, 2016  e
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Any Town, Any State 00111  Letter number: 34567 
 
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Why you are getting this letter  c
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We reviewed your application for health coverage. We determined that you do not qualify for Medicaid  e
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health coverage. To learn more, read the How we made our Medicaid decision section below. 
You might still be able to get health coverageand help 
paying for itthrough the Health Insurance Marketplace 
(Marketplace). We sent your information to them. The 
Marketplace will send you a letter. To learn more, read the  What is the Health Insurance 
Complete your Marketplace application section below.  Marketplace? 
You can use the Marketplace to shop 
How we made our Medicaid determination 
for and buy affordable private health 
We calculated your household size and income based on what  insurance online, over the phone, or 
you told us on your application and information we got from  with in-person help. There is financial 
other data sources. We found that your household size is 1  help available for people who qualify. 
person and your income is $1,915 each month. The Medicaid 
income limit for your household size is $1,273 each month. 
Since your monthly income is above the limit, you do not 
qualify for Medicaid health coverage. If you think we made a mistake, you can appeal our decision. To 
learn more, read the If you think we made a mistake section below. 
We made our decisions based on these rules: 42 CFR 435.119, 435.603. 
Complete your Marketplace application 
You should complete your Marketplace application as soon as you can to see if you can get coverage 
now. To complete your application, you can: 
1.  Start a new application at HealthCare.gov. You will need to: 
  Create a Marketplace user account if you dont have one. 
  Have this letter with you to help answer questions. 
  Fill out the application. You will need to re-enter the information you gave us already. 
  Answer yes when asked if anyone has been found not eligible for Medicaid or the 
Childrens Health Insurance Program (CHIP) in the past 90 days, if this applies. 
Or 
2.  Call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). You will need 
to: 
  Tell the Call Center Representative that your state Medicaid agency determined you are not 
 
?  Questions? Call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX). You can call Monday to Friday, 8am to 8pm.  
The call is free. Or, go to medicaid.state.gov. You can also find out how to meet with someone in person.  1  Attachment A 
 
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eligible for Medicaid, and that you want to apply for Marketplace coverage and help paying 
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for coverage.  si
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  Have this letter with you to help answer questions.  e
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  You will need to provide the information you gave us already.   
 
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3.  Wait for the letter from the Marketplace. The Marketplace is starting a health insurance  o
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application for you. The letter will tell you how to complete your application with them. 
 
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If you have questions or need help completing your application, call the Marketplace Call Center at 1-
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800-318-2596 (TTY: 1-855-889-4325). Or go to HealthCare.gov.  d 
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After you complete your application, the Marketplace will tell you if you qualify for health coverage and  d
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financial assistance to help pay for it.  M
 
The Marketplace will also tell you whether you can get health 
Your Secure User Account 
coverage now or if you have to wait and reapply. If otherwise 
eligible, you can enroll in Marketplace health coverage during a  Medicaid.state.gov keeps all 
important information about your 
certain time each year called the Open Enrollment Period. If it is 
application and health coverage. You 
not Open Enrollment when you submit your application for 
can choose to get letters like this 
coverage, you will have to wait until the next Open Enrollment 
online. 
Period, unless you have a life event that makes you eligible for a 
Special Enrollment Period. Examples of qualifying life events  To create an account, go to 
include getting married, having a baby, or losing Medicaid or  medicaid.state.gov and click 
other health coverage. You usually have up to 60 days after the  Account Setup. 
date of the life change to apply for coverage and qualify for a 
Special Enrollment Period. 
If you have special health care needs 
A person who has been denied Medicaid based on household size and income may still be able to get 
Medicaid health coverage if he or she has special health care needs. Special health care needs include if a 
person:  
  Has a medical, mental health, or substance use condition that limits his or her ability to work or go 
to school 
  Needs help with daily activities, like bathing or dressing 
  Regularly gets medical care, personal care, or health services at home or in another community 
setting, like adult day care 
  Lives in a long-term care facility, group home, or nursing home 
  Pays a lot for health care 
  Is blind 
  Is terminally ill 
If a person has any of these special health care needs, and wants to see if he or she qualifies for Medicaid, 
call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX) or go to medicaid.state.gov. If the person has 
health coverage, he or she can keep it while we are making our determination about whether he or she 
qualifies for Medicaid based on his or her special health care needs. 
 
?  Questions? Call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX). You can call Monday to Friday, 8am to 8pm.  
The call is free. Or, go to medicaid.state.gov. You can also find out how to meet with someone in person.  2  Attachment A 
  A 
 
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If you think we made a mistake 
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You can appeal our determination about your eligibility for Medicaid health coverage. For  V
 

example, you can appeal if you think we made a mistake about your household size, income, 
 
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citizenship, immigration status, or residency. You can also appeal what health services you  c
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get and how much you pay for them.  o
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To ask for an appeal, call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX). Or, go to  al
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medicaid.state.gov to get an appeals form. Or, you can write your own letter and send or  n
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bring it to us at the State Medicaid Agency, 321 Any Road, Any City, Any State 00100. You  D
 
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must ask for an appeal by August 8, 2016. 
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Once you ask for an appeal, we will see if we can fix the problem over the phone or by meeting  di
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with you. If a phone call or meeting does not fix the problem, you can have a hearing. 
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A hearing is a meeting between you, someone from the State Medicaid Agency, and a hearing 
officer. At the hearing, you can explain why you think we made a mistake. 
To get ready for your hearing, you can: 
  Ask for a copy of your file before the hearing. 
  Bring someone with you to the hearing, like a friend, relative, or lawyer, or you can come by 
yourself. 
  Bring documents, information, or witnesses to show us where you think we made a 
mistake. If a person has health coverage, he or she can keep it during an appeal. 
If you have any questions, call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX). 
 
Sincerely, 
 
State Medicaid Agency 321 Any Road 
Any City, Any State 00100 
 
We will keep your information secure and private. 
 
?  Questions? Call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX). You can call Monday to Friday, 8am to 8pm.  
The call is free. Or, go to medicaid.state.gov. You can also find out how to meet with someone in person.  3