MHA Comments on State Implementation of Presumptive Eligibility

September 24, 2013
Eligibility Policy
Bureau of Medicaid Policy and Health System Innovation
Medical Services Administration
PO Box 30479
Lansing, MI 48909
Re: Proposed MSA Bulletin 13-35, Project Number 13-21-MAGI
Dear Ms. Prokop:
I am writing on behalf of the Michigan Health & Hospital Association (MHA) to provide additional
comments (please see following pages for the MHA’s original comments, submitted Aug. 8) regarding
proposed Medical Services Administration (MSA) bulletin 13-35, which implements the Affordable Care
Act’s (ACA) Medicaid presumptive eligibility provisions. Specifically, these additional comments are
regarding the policy’s presumptive eligibility section and its divergence from what is prescribed under
the ACA.
Currently, Michigan allows qualified entities to determine presumptive eligibility only for pregnant
women and children. However, Section 2202 of the ACA expands what is permitted under presumptive
eligibility, and specifically permits hospitals to make presumptive eligibility determinations for all
income-based Medicaid populations starting Jan. 1, 2014, regardless of whether/when a state chooses
to expand its Medicaid eligibility to 133 percent of the federal poverty level.
The Centers for Medicare & Medicaid Services’ (CMS) final rule on Medicaid Alternative Benefit Plans,
Medicaid Cost Sharing, and Eligibility and Enrollment for Exchanges and Medicaid, released July 5,
outlines five criteria that a hospital must meet in order to be qualified to make presumptive eligibility
a. Participate as a Medicaid provider;
b. Notify the state Medicaid agency of its decision to make presumptive eligibility determinations;
c. Agree to make determinations that are consistent with state policies and procedures;
d. Assist individuals in completing and submitting their application (according to the state’s discretion);
e. Not be disqualified by the agency.
In addition, the final rule allows state Medicaid agencies to establish standards for hospitals that are
making presumptive eligibility determinations that would evaluate hospital performance.
We urge the MSA to revise Section 10.2 of the proposed MAGI policy, which currently allows for
presumptive eligibility only for pregnant women and children, to reflect the ACA’s expansion of
presumptive eligibility to all income-based Medicaid populations. We also urge the MSA to develop
the aforementioned standards and state policies and procedures that hospitals comply with to in order
to determine presumptive eligibility.
In addition, we encourage the MSA to reconsider the 60-day eligibility determination period outlined in
section 10.3. Under the federal expanded presumptive eligibility guidelines, hospitals will be paid for
services provided to a presumptively-eligible individual only during their period of presumptive
eligibility. While hospitals appreciate the MSA’s effort to outline a short presumptive eligibility period,
this 60-day timeframe causes us great concern. In hospitals’ experience, current eligibility
determinations for pregnant women and children often take longer than the permitted 60 days. This
timeframe poses numerous problems for healthcare providers who want to give their patients the best
care, at the right place and at the right time. With a potentially large influx of new applicants, we don’t
believe that 60 days is a realistic amount of time to determine eligibility for the newly-eligible
population. The MHA recommends:
The 60 day timeframe be expanded to 120 days for determination of eligibility and,
The policy instructs that hospitals will be paid for services up until a final eligibility
determination is made by the state, despite whether that determination is made after the
120th day of presumptive eligibility.
Thank for the consideration of our comments. If you have questions or require additional information,
please contact me at [email protected] or by phone at (517) 703-8601.
Laura Appel
Vice President, Federal Advocacy and Policy
Executive Director, MHA Health Reform Resource Center
August 8, 2013
Ms. Jackie Prokop
Bureau of Medicaid Policy & Health System Innovation
Medical Services Administration
P.O. Box 30479
Lansing, MI 48909
RE: Project Number 1321 – MAGI methodology
Dear Ms. Prokop:
On behalf of its member hospitals, the Michigan Health & Hospital Association (MHA) appreciates
the opportunity to provide comments to the Medical Services Administration (MSA) regarding the
above referenced proposed policy. Our comments are as follows:
1. We feel that there is a need for immediate clarity regarding what will happen to an individual
who applies for Medicaid under the expanded eligibility (presuming it is enacted) that begins
Jan. 1, 2014, if they apply prior to Jan. 1, 2014. For example, if it is determined that they will be
eligible under the expanded coverage, will they be enrolled and notified that their coverage
begins Jan. 1? Will their application be held and re-processed on/after Jan. 1? Will their
application simply be denied? If the latter, will they be advised to reapply after Jan. 1?
Outreach and enrollment efforts depend a great deal on the answers to these questions. It is
essential for stakeholders to know how to educate patients and the public about when and how
they can apply for Medicaid under the expanded eligibility rules.
2. Modified Adjusted Gross Income (MAGI) is never defined within the policy. We assume that the
target audience either will already know how MAGI income is computed or has no need to
know what types of income count for MAGI. There is no description in this document of the
substantive differences between current countable income and MAGI countable income (and
deductions). We urge the MSA to define MAGI in the final policy.
3. Clarification is needed as to the intended placement/audience for this policy. Currently, it reads
somewhat like the MIChild manual, which is a separate stand-alone manual. By contrast, the
MAGI eligibility rules will apply not only to the Medicaid expansion population (presuming
Medicaid expansion is enacted), but also to more than two thirds of current Medicaid enrollees.
It would appear inappropriate to have a totally separate manual for the MAGI groups.
4. Whether the audience is a Department of Human Services caseworker, Medicaid providers or
the public, it seems risky to promulgate policies separately for MAGI and non-MAGI groups that
do not differ between the two groups. The following topics do not seem to differ from existing
Medicaid policy and would be more appropriately referenced rather than repeated:
 Chapter 8 – Child Support
 Chapter 9 – Spousal Support
 Chapter 10 – Presumptive Eligibility: Please see additional comments on pages
1 and 2 of this document.
 Chapter 11 – Renewals
 Chapter 13 – Hearings
 Chapter 14 – Medicaid Benefits
5. Section 1.3: Enrollees are instructed to visit to apply for state-funded
health coverage. However, this website poses several challenges that should be addressed
before an influx of new beneficiaries are directed there:
 Under “General Directions,” item 3, the site states “If you are pregnant go to an Agency
such as a local health department to apply for MOMS and a Guarantee of Payment letter.”
These instructions do not provide enough information for pregnant women who may not
know how to contact/locate their local public health department, who may not have a local
health department, who may not have transportation, etc. It is recommended that this
item provide:
o A link to a listing of local and county health departments and their location and
contact information.
o Instructions for women who need transportation assistance to go to one of these
locations and apply.
In addition, Section 1.3 refers to the streamlined application and the two Web portals. It
should be clear that MAGI groups can also choose to apply for multiple programs using the
DHS 1171 form. The last paragraph of this section should make it clear that either Web
portal can be used.
6. In particular, the material on Hearings and Medicaid Benefits should be removed from this
document and retained in a common place for all components of Medicaid. (Comments on
these sections are included in this letter, but the above recommendation takes precedent.)
Section 1.1 anticipates that individuals will apply for assistance through a local DHS office while
section 1.5 anticipates that there will be multiple application processes. We assume that
individuals applying online for Healthy Kids and MIChild today have rights that are expressed
differently than what we see in Section 1.1. Those rights should be applicable to the MAGI
groups as well when they use an online application and should be stated in this document.
7. Section 1.5: It would be helpful to show the multiple application streams.
8. In Section 2.3 you indicate that a full-time student from another state may be considered to be
a Michigan resident. In Section 5.4 one example of household composition includes a 22 year
old individual, Jane, who attends college in Ohio. We assume that Section 5.4 correctly
indicates that Jane would be included in the household for purposes of determining Michigan
Medicaid eligibility for Bob and Mary (assuming Michigan enacts Medicaid expansion). However
Jane would likely be receiving Medicaid in Ohio (where she would also present the information
for Bob and Mary and be part of a family of three). Do we understand this correctly?
9. Chapter 3 appears to impose different standards for verification of citizenship than what is
anticipated by the Affordable Care Act. This should be verified. If, on the other hand, this
material will be identical for all components of Medicaid, this chapter should also be referenced
and not replicated.
10. Section 5.3 lists core relatives in a chapter on Household Composition. These core relatives have
no impact on household composition. The concept of core relative is only used for authorized
representatives (Section 1.4) and in relationship to Child Support (Section 8.3). Because core
relatives are defined in Chapter 16, we recommend that Section 5.3 be removed.
11. Section 5.4 provides two very unusual household composition examples. We believe that you
have correctly interpreted the regulations in that Joy is part of a household of two. However,
this item would be clearer if you indicated that the only income counted for determining Joy’s
eligibility is the income of Samantha and Joy.
12. Section 7.2 uses the Michigan term “Spousal Support” rather than the CMS term “Alimony.”
This should be checked against the final version of the streamlined application developed for
Michigan. Also, “Other Pensions” would be a good category to add to this partial list of income
sources that are counted as MAGI.
13. Section 10.2: Clarification is needed as to whether pregnant women and children are
automatically given presumptive eligibility, or whether it is dependent upon review of their
14. Section 11.2: Clarification is needed regarding when renewal packets are sent and how much
time the beneficiary has to complete and return the information. The current verbiage indicates
that renewal packets are sent just three days prior to a beneficiary being cut off; however, it
then states that the beneficiary has 10 days to return the information.
 We request the final policy clarify when renewal packets are sent.
 We request the policy clarify whether the 10-day count begins the day after the packet is
post-marked, or whether it begins the date the packet is delivered or received by the
beneficiary. Also, whether the returning packet must be post-marked by the 10th day or
received by the MDCH by the 10th day. Ample time should be given for the beneficiary to
receive, complete and return the requested information. Regardless of the response to the
above question, we do not believe that 10 days is ample time.
15. Section 11.4: The current verbiage states that “timely notice of Medicaid case closure” must be
given when an individual is no longer eligible or fails to provide the requested information.
However, “timely” is not defined for these purposes. We recommend that a specific amount of
time be defined for notifying beneficiaries that they will no longer be eligible for medical
16. Chapter 8 on Child Support reads like a section of DHS policy related to financial assistance
programs. Child Support cooperation is not required for Medicaid. A Chapter on Medical
Support would, however, be appropriate.
17. Chapter 14 on Medicaid Benefits indicates that “Plus Care recipients” are excluded from
enrollment in a Medicaid Health Plan. There is no Plus Care program. This program existed in
Wayne County prior to the implementation of the Adult Benefits Waiver. The same section
indicates that persons residing in an Intermediate Care Facility for the Mentally Retarded
(ICF/MR) are excluded from health plan enrollment. Michigan no longer has any ICF/MR
facilities. (In states that still have these facilities they are now Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICF/DD or ICF/IID).)
18. Chapter 15 on Institutional Status must be reviewed by the Behavioral Health and
Developmental Disabilities Administration. In particular, the Institution for Mental Diseases
(IMD) exclusion disqualifies individuals from receiving Medicaid-funded services but does not
make them ineligible for Medicaid. All of Michigan’s private psychiatric hospitals and some
psychiatric units are IMDs under the provisions of Section 4390 of the State Medicaid Manual
and individuals treated in those facilities retain their Medicaid eligibility.
Thank for the consideration of our comments. If you have questions or require additional
information, please contact me at [email protected] or by phone at (517) 703-8601.
Laura Appel
Vice President, Federal Advocacy and Policy
Executive Director, MHA Health Reform Resource Center