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Washington Highlights

CMS Issues Final Rule on Medicaid and Exchanges Eligibility and Enrollment

July 12, 2013—The Centers for Medicare and Medicaid Services (CMS) July 5 issued a final rule to implement provisions of the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152) related to eligibility and enrollment in Medicaid, the Children’s Health Insurance Program (CHIP), and coordination with the health insurance exchanges (“health insurance marketplaces”).  The final rule will be published in the Federal Register on July 15. The rule is effective Jan. 2014.

The final rule includes the following:

  • Starting in Jan. 2014, qualified hospitals may self-elect to make presumptive eligibility determinations for Medicaid-eligible populations.  To be authorized to make presumptive eligibility determinations, a hospital must:

    • participate as a Medicaid provider;
    • notify the state Medicaid agency of its decision to make presumptive eligibility determinations;
    • agree to make determinations consistent with state policies and procedures;
    • assist individuals in completing and submitting the full application, at the states’ discretion; and
    • not be disqualified by the agency.
  • Implementation of the ACA requirement that Medicaid alternative benefit plans (ABP) include essential health benefits (EHB).  CMS outlines a process for states to follow to ensure that the ABP for the group of low-income adults newly eligible through Medicaid expansion meet the ACA’s EHB requirements
  • A change in the maximum nominal limit for outpatient services for those with incomes below 100 percent of the federal poverty level (FPL) from $3.90 to $4.00 beginning FY 2014.
  • Permitting cost-sharing of up to $8.00 without a waiver for non-emergency use of the emergency department (ED) for individuals with family incomes up to 150 percent of the FPL.

  • Clarification of language regarding hospitals’ obligation to inform individuals seeking treatment through the ED that alternative sources of treatment are available in the community, and that proceeding with ED treatment will result in cost-sharing.  The final rule allows hospitals to “determine” rather than “ensure” (CMS’ original proposal) that an alternative source of care in the community can provide care in a timely manner. 

  • Reinstatement of language that hospitals must provide a referral to coordinate scheduling for treatment by an alternative provider, rather than finalizing a proposal that would have imposed more requirements on a treating hospital before imposing cost-sharing for non-emergency use of the ED. 

  • CMS explains that it is important that scheduling be done on-site, with the beneficiary present, to the maximum extent possible, but recognized that this may not be possible during certain hours of the night.  In these instances, CMS encourages hospitals to conduct follow-up scheduling and take advantage of the existence of a call line and assigned primary care providers in satisfying the coordination requirements.

AAMC’s comments on the proposed rule focused on presumptive eligibility determinations by hospitals, proposals to increase nominal cost-sharing limits, and requirements for Medicaid benchmark and benchmark-equivalent plans (now referred to as “Alternative Benefit Plans”) [see Washington Highlights, Feb. 15]. 


Allison M. Cohen, J.D., LL.M.
Senior Policy and Regulatory Specialist
Telephone: 202-862-6085

Ivy Baer, J.D., M.P.H.
Senior Director and Regulatory Counsel
Telephone: 202-828-0499



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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806