How Do Updated 2014 Federal Poverty Level Thresholds Impact Medicaid, CHIP & Premium Tax Credit Eligibility?

By Martha Heberlein

Updated 2014 federal poverty thresholds were released on January 22nd and inquiring minds have been asking what they mean in terms of determining eligibility for Medicaid, CHIP, and premium tax credits. And the answer, as with so many things in our world is, “well, it depends.”

Let’s start with premium tax credits as that’s the easiest to explain – the “reference” FPL (the one that income/household size is compared to in order to determine eligibility) is the most recently published FPL as of the first day of open enrollment. So, since open enrollment began in October 2013, the 2013 FPL has been used for determining eligibility for premium tax credits in the marketplaces and will continue to be the reference FPL until the next open enrollment period begins on November 15th.

As for Medicaid, the reference FPL is that which is in place at the time of application. Since Medicaid agencies have the flexibility to determine when they adopt the new FPLs, what’s considered “in place” differs from state-to-state, although states typically update to the new FPL by April.

To add to the complexity – CMS released guidance on Friday stating that the FFM will move to using the 2014 FPLs today, Monday, February 10th. Now consumers applying to the FFM will have Medicaid/CHIP eligibility determined using the 2014 FPL; however, it is unclear as to what happens if that consumer is determined ineligible when sent to a Medicaid/CHIP agency that is still utilizing the 2013 FPL. (And it doesn’t sound as if they’ll reconsider anyone who may have had a different eligibility determination if they applied on Friday vs. today based solely on the change in the FPL.)

CMS has told states to move to the 2014 FPL “as soon as practicable” to align with the standards used by the FFM. This is a welcome protection for consumers and hopefully will help to avert another “looping” problem where consumers are shuffled back and forth between programs.

As for the disconnect with the determination of premium tax credits, we think folks should be safe. Since consumers should be screened for Medicaid first (and the FPL only rises), the FPL used for determining eligibility for Medicaid will be higher than that used for premium tax credits. As such, those on the cusp, should be correctly assessed as eligible for Medicaid (although this is kind of a moot point in non-expansion states).