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CMS issues final rule on Medicaid, CHIP, Marketplace provisions

July 8, 2013

The Centers for Medicare & Medicaid Services Friday issued a final rule implementing provisions of the Patient Protection and Affordable Care Act related to eligibility and enrollment for Medicaid, the Children’s Health Insurance Program and health insurance exchange-based premium tax subsidies. With regard to Medicaid, the rule provides guidance to states implementing coverage for the new low-income adult group beginning in 2014. The guidance includes giving states additional time to design their Alternative Benefit Plans (benchmark plans), which include the ACA require “essential health benefit.” In addition, the rule implements the ACA provision requiring that states allow hospitals to make presumptive eligibility determinations for potential Medicaid patients seeking care. The rule also implements a single set of rules for Medicaid premiums and cost sharing, while allowing states to impose higher cost sharing for non-emergency use of hospital emergency departments and non-preferred drugs. The final rule allows individuals applying for exchange-based premium subsidies to self-attest to whether they are offered employer-based health coverage. The final rule does not address all provisions included in the January proposed rule. The agency said it intends to address the remaining provisions, including proposed certification standards for counselors who help people apply for qualified health plans through an exchange or insurance affordability program, in future rulemaking. AHA is reviewing the 606-page rule and will provide more information to members soon in a Special Bulletin.