States with Partnership or Federally Facilitated Marketplaces are coordinating with the Federal Government on Medicaid eligibility and enrollment. Each state Medicaid agency has chosen whether the Marketplace will assess or determine Medicaid eligibility for individuals applying through the Marketplace. When an individual applies for coverage in states that have elected not to establish their own Marketplaces, the federal Marketplaces should always consider the individual’s eligibility for Medicaid. If a state has chosen the assessment model, the federal marketplace makes an initial assessment of eligibility for Medicaid, and the state Medicaid agency makes the final Medicaid eligibility determination. In states that have chosen the determination model, the federal Marketplace makes the final Medicaid eligibility determination and transmits this determination to the state Medicaid agency. Regardless of the model the state has chosen for determining an individual’s Medicaid eligibility, the process should be streamlined with minimal burden on the applicant. The state Medicaid agency will continue to have final oversight of the accuracy of all eligibility determinations, including those made by Marketplaces.
States that are participating in the Medicaid expansion program have selected a benchmark plan among several types of health plans. The benchmark plan will be used to establish Alternative Benefit Plan benefits. While states have the flexibility to make the Alternative Benefit Plan the same as the traditional benefits available in Medicaid, they also have the flexibility to offer different benefits, provided the plan covers the ten essential health benefits services categories.
Most people who are eligible for the expansion group will receive Alternative Benefit Plans. However, states also have the flexibility to establish more than one plan and identify specific plans to meet the needs of certain groups including people with certain health conditions. States also have the flexibility to add Home and Community-Based Services (HCBS) to their Alternative Benefit Plan packages. In general, most states appear to be choosing Alternative Benefit Plan packages for the expansion group that are the same as the state’s standard Medicaid package. At the same time, at least a few states are seeking permission from the Center for Medicare and Medicaid Services (CMS) to apply conditions that come with traditional Medicaid to the expansion package. So, for example, a state could seek to apply an asset test to individuals in the expansion Medicaid group before they can access Medicaid long-term services and supports (which includes HCBS), even though the expansion group is supposed to qualify for Medicaid on the basis of income alone. Navigators need to be aware of these important nuances and help people with disabilities, who currently or in future may rely on HCBS to remain in their homes and communities, to understand any special conditions in their state.
Some people who are eligible for the newly expanded Medicaid program and who may have greater medical needs will not be required to enroll in the Alternative Benefit Plan. For example, eligible people who are blind or who have a disability, are eligible for both Medicaid and Medicare, or who are “medically frail” can choose to enroll in traditional Medicaid if the state’s Alternative Benefit Plan does not include that state’s full slate of Medicaid state plan benefits. (See 42 C.F.R. § 440.315.) Federal regulations issued in July, 2013 give states some freedom to define “medically frail” but establish that, at a minimum, the definition of “medically frail” includes children with serious emotional disturbances, individuals with disabling mental disorders, individuals with serious and complex medical conditions, and individuals with physical and/or mental disabilities that significantly impair their ability to perform one or more activities of daily living.
In states where traditional Medicaid and the Alternative Benefit Plan differ, traditional Medicaid may offer more benefits, services, and prescription drug options than the Medicaid Alternative Benefit Plans. Similarly, physician and provider networks may be larger with more options for specialty care and services such as rehabilitation and habilitation. Therefore, Navigators should help applicants understand if they might meet the newly expanded definition of “medically frail.” Navigators also should make sure that individuals understand that it will be important to check the state’s definition of “medically frail” to determine if additional eligibility requirements, such as an asset test apply in order to qualify as “medically frail.” Ultimately, if a given state’s Alternative Benefit Plan offers the same benefits as their traditional Medicaid plan, then it is not significant if the individual fits the state’s definition of “medically frail” or not. If the Alternative Benefit plan and the traditional Medicaid plan differ, then the individual, with the help of the Navigator, should give very careful consideration to the different Medicaid options available to them.