Our Initial Take on Today’s Final Medicaid, CHIP, Exchange Rule

I’m holding the fort down at CCF while most of my colleagues get a few well-deserved days off. But unfortunately that means I drew the short straw for a first look at final Medicaid and Exchange regulations released on this hot, humid day wedged between a national holiday and what could be a long weekend. I thought a good place to start would be to see how our top issues for children and families (which were outlined in this blog) fared. The rule will be published in the federal register on July 15, and finalizes many but not all of the provisions proposed in what we have affectionately referred to as the ‘cats and dogs regs.’ Four of our eight priority issue areas were addressed in this set of regulations:

  • Develop a contingency plan for states not ready by October 1, 2013. The final regulations acknowledged our concerns about state readiness to implement the single, streamlined application by October 2013, particularly the risk that people who apply for coverage through the federally-facilitated exchange (FFE) and are instead assessed as eligible for Medicaid or CHIP could slip through the cracks. While not addressing this issue in the final regulations, CMS did affirm that it is actively working with states on implementation and “mitigation” strategies when necessary. As I noted earlier, we are hopeful that states will be transparent about how things will work on October 1 and beyond as changes are introduced. Doing so will help set expectations for all stakeholders and better prepare navigators and other assisters to help consumers when interim eligibility and enrollment processes (a.k.a. mitigation strategies but more often called ‘work-arounds’ in the policy world) are in place.
  • Eliminate CHIP waiting periods. This was the “big ask” in our comments on the proposed regulations, and frankly we’re disappointed that the Administration missed an opportunity in their rulemaking to eliminate this red-tape barrier to continuous coverage, which can have lifelong consequences for children who are left uninsured for even small amounts of time. In a post-ACA universe where everyone is expected to have health insurance, it makes no sense to require uninsured children to wait up to 90 days to enroll in CHIP. To be fair, the final rule does limit waiting periods to no more than 90 days and requires states to implement specific exemptions to the waiting period. And while children can be enrolled temporarily in the exchange, states must keep track of when the waiting period expires and take steps to then enroll the child in CHIP. The rule also encourages states to examine the costs and benefits of imposing a waiting period in the context of the ACA and reiterates that waiting periods are NOT required. CMS confirms a state’s ability to eliminate waiting periods, just as Vermont and Colorado have done this year, and Washington and Maryland plan to do soon. This issue will remain a top priority for CCF and child health advocates in the coming weeks and months, so stay tuned for lots more on this topic!
  • Hold onto and improve those new “certified application counselors.” Say Ahhh! has been my soap box in raising concerns over the adequacy of navigator and other consumer assistance resources to help connect kids and their families to coverage. So, we are pleased that the final rule formalizes a new certified application counselor (CAC) program in Medicaid and CHIP. One change is that the final rule eliminated the requirement that states must provide a specific web portal through which CACs would facilitate enrollment. However, the rules did not include the final provisions regarding CACs in exchanges but noted they will be released at a later date. I’m betting exchange CAC rules will be released along with the final navigator conflict of interest and training standards, which are expected soon. I’ll dig into the details of Medicaid and CHIP CACs in a future blog.
  • Clarify that the cost-effectiveness test for premium assistance must take cost-sharing protections into account. CMS did strengthen the cost-effectiveness test by requiring that it include health plan cost sharing and the cost of administering a cost-sharing wrap. CMS also reaffirmed that participation in premium assistance must be voluntary and clarified that states taking this option must ensure that individuals understand their choice to receive direct coverage under Medicaid or through premium assistance. (Our resident premium assistance guru, Joan Alker, is enjoying the last few days of her vacation so you’ll no doubt be hearing more on the premium assistance regulations when she returns.)

As to our other top issues that were not included in this final rule, we remain hopeful that when CMS releases additional final regulations they will:

  • Strengthen regulations to ensure that the babies born to all women enrolled in Medicaid or CHIP are automatically signed up for coverage for the first year of life.
  • Provide former foster care children with a secure source of coverage up to age 26 even if they move to a new state.
  • Retain and strengthen the proposed simplifications to paper-based documentation of citizenship.
  • Adopt a more inclusive definition of “lawfully present.”

I am happy to share the bigger task of taking a closer look at the rule and its implications for children and families with my CCF colleagues, including a few returning from vacation just in time to dig in. So check back on Say Ahhh! for more on the final rule in the coming weeks.



Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.