42 cfr 431.211. 42 CFR 431.213 2019-03-04

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42 CFR 431.231

42 cfr 431.211

This is important for people who will churn between Medicaid, the commercial markets and potentially a state basic health plan. Response: We agree with the commenter, and the provision has been amended by removing redundant language in § 435. Comment: Some commenters recommended that states only be permitted to terminate coverage during a continuous eligibility period for failure to pay premiums as proposed at § 457. No comments were received regarding these specific provisions. We will also continue to offer intensive technical assistance and support to states, and facilitate sharing of experience and knowledge across states. This is because an assessment is not a final Medicaid eligibility determination. Provisions of the Proposed Regulations and Analysis of and Responses to Public Comments A.


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[42 CFR 431] Title 42 Part 431 : Code of Federal Regulations

42 cfr 431.211

Response: The flexibility to provide specialized benefit packages to one or more targeted populations is at the option of the state. They believe that this should be clarified in the final rule to explicitly include cost sharing. They believe that explicitly requiring freedom of choice will increase the likelihood that all plans will comply with the freedom of choice requirement. Response: Annual dollar limits are prohibited in the public employee or commercial plans that are the basis for coverage options and the base benchmark options according to section 2711 of the Public Health Service Act. Availability of agency program manuals.

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» 42 CFR 431.230

42 cfr 431.211

Response: We have provided in § 431. Balance requirements of e also apply. The State plan must provide that the Medicaid agency has in effect a written agreement with the State mental health and Intellectual Disability authorities that meets the requirements specified in paragraph c of this section. Such notice must be provided orally or through electronic means in accordance with §435. However, there are similar protections in place in the regulations governing Medicaid managed care plans.

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Reference

42 cfr 431.211

Response: We clarify that the definition is not the same. Consumer safeguards were proposed to ensure that individuals make a conscious choice to receive notices in electronic format, and would be able to opt-in and opt-out of their election. Another commenter noted that Medicaid eligibility systems, policies and staff are not structured to operate in a time-limited open enrollment environment or to apply competing eligibility criteria concurrently, and cannot be changed to do so with only a few months' notice. It also means a determination by a skilled nursing facility or nursing facility to transfer or discharge a resident and an adverse determination by a State with regard to the preadmission screening and resident review requirements of section 1919 e 7 of the Act. Hospital and physician laboratories may participate in competitive bidding only with regard to services to non-hospital patients and other physicians' patients, respectively. As long as that floor is met, Medicaid beneficiaries in the new adult group can also receive benefits from the selected coverage options under section 1937 of the Act or through substitution of benefits. To establish a more timely and effective notification process, proposed § 435.

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eCFR — Code of Federal Regulations

42 cfr 431.211

Commenters recommended that Medicaid agencies not be required to begin accepting streamlined applications or determinations from the Exchange prior to January 1, 2014. Comment: A few commenters suggested that we revise § 431. They assert that this would result in significant financial cost to states to expand benefits to all adults as new benefits for the existing population are ineligible for the enhanced match offered under the Affordable Care Act for the newly eligible expansion population. One example of how an individual might demonstrate that he did not receive an electronic eligibility notice is by providing documentation that he closed the email account on record with the agency. Comment: Many commenters are concerned that there is no requirement regarding adequacy of benefits. We appreciate the concern expressed for ensuring consumer protections against delivery error.


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1982.09.30 DAB346 Pennsylvania Department of Public Welfare

42 cfr 431.211

Below we discuss the State's arguments on why this appeal should be granted, and our analysis of why it cannot. Response: We believe that it is an important consumer protection to allow individuals to request notices in a paper format. We do not think it is appropriate or operationally feasible to require other types of communications to be provided electronically. The Board is not persuaded that the Agency's interpretation is irrational or absurd. Response: We agree that all eligibility notices must be accessible to persons who are limited English proficient and individuals with disabilities, and we will be addressing such rules in future rulemaking.

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42 CFR 431.213

42 cfr 431.211

The disregard would not be applied for a determination of eligibility for a particular eligibility group, but rather for eligibility for Medicaid. Regular coverage or regular Medicaid benefit package is defined as Medicaid state plan services including services defined in section 1905 a , 1915 i , 1915 j and 1945 authorities. B To the extent applicable, the proposed health care delivery system and the eligibility requirements, benefit coverage and cost sharing premiums, co-payments, and deductibles required of individuals that will be impacted by the demonstration, and how such provisions vary from the State's current program features. Summary: We have not made any changes to regulation text, based on public comments received. These mechanisms will need to be coordinated with the health plan to successfully implement a premium assistance program.

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Reference

42 cfr 431.211

Ultimately, this standard must make clear that the determination of whether a coverage limitation or exclusion is discriminatory should turn on the degree to which the benefit design is based on sound standards of clinical appropriateness rather than on arbitrary distinctions between health conditions or personal characteristics. A State plan, except the plan for Puerto Rico, the Virgin Islands, or Guam, must provide as follows: 1 Except as provided under paragraph c of this section and part 438 of this chapter, a beneficiary may obtain Medicaid services from any institution, agency, pharmacy, person, or organization that is— i Qualified to furnish the services; and ii Willing to furnish them to that particular beneficiary. The commenter also stated that the proposed rule increases costs for states and the federal government, and diminishes health outcomes for children. We have separated the regulation text as proposed at § 435. We believe this will allay concerns expressed by commenters, as commercial plans must also adhere to mental health parity requirements. Thus, promoting seamless coverage for this population and ensuring coordination of care during coverage transitions will be critical.

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[42 CFR 431] Title 42 Part 431 : Code of Federal Regulations

42 cfr 431.211

Comment: One commenter asked us to confirm that the definition provided for authorized representatives is the same definition that the Social Security Administration uses. Medicaid Premiums and Cost Sharing Section 1916 of the Act describes long-standing limitations and requirements applicable in states that elect to provide for premiums and other cost sharing under Medicaid. Payment for services is guaranteed during a presumptive eligibility period; without such a guarantee, providers could not rely on the determination. For example, states can indicate that a beneficiary has an authorized Start Printed Page 42175representative and remind the individual that they may keep or change the representative on the renewal document. If the state has delegated authority to the Exchange to conduct fair hearings under these regulations, such an individual found ineligible for Medicaid by the Exchange could request a fair hearing at the Exchange or Exchange appeals entity so that there would be one integrated hearing conducting the Exchange-related and Medicaid appeals at the same time, or the individual may instead request his or her Medicaid issue be heard at the Medicaid agency. Some commenters recommended that health insurance issuers, their subsidiaries and licensed insurance brokers and agents be explicitly excluded from being certified as certified application counselors given their inherent financial conflict of interest.

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eCFR — Code of Federal Regulations

42 cfr 431.211

The agency may a not later than the if - a The agency has factual information confirming the death of a ; b The agency receives a clear written statement signed by a that - 1 He no longer wishes services; or 2 Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information; c The has been admitted to an institution where he is ineligible under the plan for further services; d The 's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address See d of this subpart for procedure if the 's whereabouts become known ; e The agency establishes the fact that the has been accepted for services by another local jurisdiction, State, territory, or commonwealth; f A change in the level of medical care is prescribed by the 's physician; g The involves an made with regard to the preadmission screening requirements of section 1919 e 7 of the ; or h The will occur in less than 10 , in accordance with 8 , which provides to the 30 requirements of of this chapter. One state reported that during an almost 15-year period, there has been no evidence that crowd out is a concern, including for children at higher income levels. The second mailgram informed the State that the effective date of the decision would be delayed because a rehearing in the case had been requested. The Board is bound by applicable laws and regulations. We address the issue of requiring enrollment in premium assistance for certain populations in the last response in this section.

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