Medicaid, CHIP, and the Affordable Care Act

The Affordable Care Act significantly streamlines the eligibility standards and enrollment processes for Medicaid. It also offers a new opportunity for states to expand Medicaid to all adults ages 19 – 64 with household MAGI at or below 138% of the FPL. States have the option to expand Medicaid eligibility to this new eligibility group. This is known as “Medicaid expansion.”

Through Medicaid expansion, the Affordable Care Act provides new opportunities for adults in some states to be covered by Medicaid. However, some states have chosen not to expand Medicaid eligibility to these income levels. Even if a state did not expand Medicaid, it will still cover pregnant women and children above the poverty level – and in some cases, will cover children through CHIP with income at several times the poverty level.

When an individual indicates on his or her application that he or she is interested in help paying for health insurance, the Marketplace conducts an eligibility assessment or determination for Medicaid and CHIP for each family member that the applicant indicates needs health insurance coverage. Certain family members may qualify for Medicaid, even if other family members do not and will need to purchase health insurance coverage through a Marketplace. For instance, if a couple has a child under age 26 who files his or her own tax return, that child may be eligible for Medicaid even if his or her parents are not. Additionally, a family member may qualify for Medicaid due to a disability, while the rest of the family purchases health insurance through the Marketplace.

Similarly, there may be instances where the parent(s) of a family may obtain health insurance through the Marketplaces, while their child does not enroll in the family’s QHP because he or she is determined to be eligible for CHIP coverage. Parents can only receive the cost-sharing reductions and the premium tax credit that they are determined to be eligible for by enrolling in a QHP through a Marketplace. These affordability programs are not available for those who are determined to be eligible for minimum essential coverage through Medicaid or CHIP.

Have more questions about your eligibility for an affordability program with the Affordable care Act and how it integrates with your health insurance coverage? Contact your Total Benefit Solutions ACA experts toda at (215)355-2121 or (800)924-6718.