Overview
Summary of CMCS program history and related initiatives for Medicaid, CHIP, and the Basic Health Program, including ACA impacts.
CMCS Role
- CMCS leads national policy and operations for Medicaid, CHIP, and BHP.
- Programs serve families, children, pregnant individuals, adults without children, seniors, and people with disabilities.
Medicaid
- Authorized by Title XIX of the Social Security Act; enacted in 1965 with Medicare.
- Available in all states, DC, and U.S. territories for low-income individuals.
- Federal rules set parameters; states administer programs, creating coverage variations.
Children’s Health Insurance Program (CHIP)
- Enacted in 1997; provides federal matching funds for children’s coverage.
- Targets children in families above Medicaid income limits lacking private insurance.
- Nearly all states cover children up to at least 200% of the Federal Poverty Level.
Basic Health Program (BHP)
- Created by the Affordable Care Act (ACA) as a state option.
- Offers affordable coverage for low-income residents near Medicaid/CHIP thresholds.
- Supports continuity of care for individuals with fluctuating incomes.
Affordable Care Act (ACA) Overview
- From 2014, states can expand Medicaid to under-65 with incomes below 133% FPL.
- Standardizes eligibility and benefits across Medicaid, CHIP, and the Marketplace.
- Establishes coordinated application using a single process across programs.
ACA Key Provisions Summary
| Provision | Description |
|---|
| Eligibility | Sets a nationwide minimum Medicaid income eligibility to close coverage gaps. |
| Financing | Federal funds fully cover newly eligible adults for 3 years starting 2014; phases to 90% by 2020. |
| IT Systems and Data | Policies and financing equip states to invest in systems for the 1/1/2014 launch and eligibility expansion. |
| Coordination with Exchanges | Single application determines eligibility for all insurance affordability programs. |
| Benefits | Newly eligible receive benchmark or equivalent coverage including minimum essential benefits. |
| Community-Based LTSS | Improves programs and funding for home and community long-term services and supports. |
| Quality and Delivery Systems | Enhances care quality and delivery while reducing costs. |
| Prevention | Promotes prevention, wellness, and public health at all government levels. |
| CHIP | Extends CHIP funding through FY 2015; maintains program authority through 2019. |
| Dual Eligibles | Creates a CMS office to coordinate care for Medicare-Medicaid enrollees. |
| Provider Payments | States receive 100% federal match for payment increases. |
| Program Transparency | Increases transparency; ensures public input on state and federal Medicaid waivers. |
| Program Integrity | Strengthens integrity: cross-program terminations, payment suspensions for suspected fraud, prevents improper payments. |
Key Terms & Definitions
- Federal Poverty Level (FPL): Income measure used to determine eligibility thresholds.
- Benchmark Benefit Package: Standardized set of essential benefits for newly eligible Medicaid enrollees.
- Dual Eligibles: Individuals eligible for both Medicaid and Medicare.
- Long-Term Services and Supports (LTSS): Services aiding individuals with chronic conditions or disabilities in home or community.
Action Items / Next Steps
- States consider Medicaid expansion to below 133% FPL for under-65 populations.
- Implement and maintain eligibility and benefits coordination with Marketplaces.
- Invest in and operate IT systems supporting streamlined eligibility and enrollment.
- Advance community-based LTSS, quality improvements, and program integrity measures.