GIS 11 MA/021: Increase Medicaid Income Standard for Children Ages Six through Eighteen from 100% FPL to 133% FPL

The purpose of this General Information System (GIS) message is to inform local departments of social services (LDSS) of an increase in the Medicaid eligibility income level for children age six through eighteen from 100% of the Federal Poverty Level (FPL) to 133% FPL.

There are currently three FPL standards used to determine Medicaid eligibility depending on the age of the child: 200% FPL for children up to age one; 133% FPL for children ages one through five; and 100% FPL for children age six through eighteen. Effective November 1, 2011, all children who are ages one through eighteen will have income compared to a single income standard of 133% FPL. This change will simplify the Medicaid eligibility determination process because it will reduce situations in which some children in the household are Medicaid eligible while others are Child Health Plus (CHPlus) eligible. This will eliminate the need for children to transfer to CHPlus simply because they have turned age six. Children under the age of one will continue to have eligibility determined up to 200% FPL.

There will be no local share for the program costs associated with the expansion of coverage to children whose family income exceeds 100% of the FPL but does not exceed 133% of the FPL. An enhanced federal reimbursement of 65% ll be received for this population of children.

Effective with the October 17, 2011 WMS/CNS migration, the Medicaid budgeting methodology (MBL) will calculate eligibility for children ages six to eighteen, with budget "From" dates of November 1, 2011 or later, up to 133% FPL. When determining eligibility for a child under the age of nineteen, districts must enter the Expanded Eligibility Code (EEC) of "D" – Children 6+<19 or the EEC of "B" which also calculates the level for all children under the age of nineteen. Children currently enrolled in Medicaid with a spenddown must be reviewed at the next renewal and eligibility evaluated at the higher income standard.

Individual Category Code (ICC) "84" has been created to identify children between 6 and 18 years of age eligible at the income level greater than 100% FPL but less than or equal to 133% FPL. This new ICC can be used on a Case Type 20 or 24. Children with an ICC of 84 are entitled to continuous coverage, and a Continuous Save Date (CSD) will be system generated when opening or renewing a child using this category code. The existing ICC 47 must be used when authorizing Medicaid coverage for a child 6-18 years of age, eligible with income less than or equal to 100% FPL.

MBL budgets with an effective date of November 1, 2011, or later, will calculate and display one of the two FPLs as appropriate; less than or equal to 100% FPL or greater than 100% FPL but less than or equal to 133% FPL when using the EEC of "D" These values will also be displayed when using EEC of "B".

NOTE: The correct Individual Categorical Code is necessary to assure the appropriate eligibility category and claiming.

Client notices have been updated to reflect the increased income level.

The Upstate Reason Codes/Paragraph Numbers have been revised. The following notices will be used for children one through eighteen: S88/D0158, U91/C0226, S20CC/X0231, S20CE/X0230, S20CG/X0229, S20CA/X0228, U33/X0170, F83/U0142, F82/U0138, U90/U0112 and explanatory paragraph #E0019.

The following Upstate Reason Codes/Paragraph Numbers will be deleted since there is no longer a need for separate notices for children six through eighteen and for children turning six: E45/X0065, E55/X0077, E56/X0078, E44/X0064, E56/X0061, E55/X0060, S20BA/X0149, S20BG/X0151, S20BE/X0154, S20BC/X0157.

In NYC new Reason Code FE1 "Excess Income – child 6-18 above 133% FPL" for rejection/closing on a Case Type 20 has been enabled. FE1 is also enabled at the line level for Case Types 20 and 24. If a Case Type 20 includes children age one through five and children age six through eighteen, whose Medicaid is being discontinued because of excess income over 133% FPL, then case Reason ode "Y99" must be used and a manual notice must be sent.

Express Lane Eligibility (ELE) that was scheduled to be implemented with the increase of the income level for children six through eighteen has not been finalized. Policy staff and system staff are still working on this project. Further information will be released as soon as it becomes available.

Please direct any questions to your local district liaison.