How Do Updated 2015 Federal Poverty Level Thresholds Impact Medicaid, CHIP & Premium Tax Credit Eligibility?

Over the weekend, Healthcare.gov uploaded the new 2015 federal poverty levels (FPL) to use in assessing eligibility for Medicaid and CHIP. What does this mean to consumers applying for coverage?

Let’s start with eligibility for Marketplace subsidies. For 2015 calendar year coverage, regardless of when someone applies or enrolls, eligibility is based on the 2014 FPL levels. For those more interested in the specifics, the most recently published FPL “as of the first day of open enrollment” remains in force for the full calendar year of coverage. Since enrollment opened on November 15 2014, the 2014 FPL levels will be applied for eligibility purposes for coverage for all of calendar year 2015.

For Medicaid and CHIP, the FPL that is in place “at the time of application” is used to determine eligibility, but Medicaid agencies have flexibility as to when they adopt the new FPLs. States typically make their system changes no later than April 1, and some move quicker than that. Last year, CMS encouraged states to adopt the new FPL levels as soon as practical. In the interim, some states may employ workarounds to account for the difference in the FPL levels. For example, they could “pend” applications “in the gap” until the system change has been made (as long as it’s not more than 45 days).

In the 39 states that rely on Healthcare.gov for Marketplace eligibility and enrollment, there could be a short period of time when the state Medicaid/CHIP system continues to use the 2014 guidelines while the FFM has moved on to the 2015 guidelines.

What does this lack of coordination mean for consumers?

If an individual or family has income that falls into the difference between the two guidelines, it could be tricky. For example, 138% of the 2015 FPL level for an individual is now $16,243 – up from $16,105 last year. If an individual has income at $16,200, Healthcare.gov will transfer the account to the state to determine Medicaid eligibility. But if the state has not yet implemented the new level, it will deny Medicaid. Sometimes states will use a workaround to account for the gap in implementation, but we don’t have specific state-by-state information that tells us which states use workarounds or when states will put to the new FPL into place.

Just to make this dance a bit more interesting, we should distinguish between states that allow Healthcare.gov to make the final Medicaid or CHIP determination versus states that only allow the federal Marketplace (FFM) to “assess” Medicaid eligibility. According to the 2015 50-state survey, 10 states (AL, AR, LA, MT, NJ, ND, OR, TN, WV, WY) are currently “determination” states. The state must accept the FFM’s determination, so the state should enroll, not deny, Medicaid or CHIP coverage to everyone who applies through Healthcare.gov.

In the 12 states (CO, CT, DC, ID, KY, MD, MA, MN, NY, RI, VT, WA) with an integrated State-based Marketplace and Medicaid eligibility and enrollment system, we anticipate that the changeover will not be an issue.

That leaves us with 27 “assessment states,” plus CA and HI, where there could be a lack of coordination. For the list of assessment states, see Table 12, page 47 of the 2015 50-state survey. As for CA and HI, these states have separate Marketplace and Medicaid eligibility and enrollment systems and it’s not clear how, or if, they will coordinate adoption of the FPL levels for Medicaid and CHIP eligibility.

Needless to say, this is a bit confusing. And it should work itself out within a few weeks. But enrollment assisters should be on the lookout for people who could be bounced between coverage options to make sure they get enrolled in the right program.

Tricia Brooks
Tricia Brooks is a Senior Fellow at the Center for Children and Families

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