Overview of Final Medicaid Eligibility Regulation

This brief provides an overview of the final and interim final rules codifying Medicaid eligibility and enrollment provision of the Patient Protection and Affordable Care Act (ACA). The two sections of the brief offer (1) a high level overview of important highlights, focusing on key areas that have changed or expanded upon previous guidance, and (2) a section-by-section summary of the regulation.

Specifically, the Medicaid final rule:

  • Expands Medicaid eligibility for non-disabled adults;
  • Simplifies Medicaid eligibility categories;
  • Modernizes eligibility verification rules, relying primarily on electronic data sources;
  • Streamlines Medicaid and Children’s Health Insurance Program (CHIP) applications and renewals; and,
  • Coordinates eligibility across Medicaid, CHIP, and the Health Insurance Exchange (Exchange).

While providing states with additional flexibility, the final regulation requires Medicaid/CHIP agencies to ensure that the eligibility determination process for all Insurance Affordability Programs (IAPs) and Medicaid programs for non-modified adjusted gross income (non-MAGI) individuals is coordinated, seamless and conducted promptly and without reasonable delay.

This brief is provided by the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation, which provides in-depth technical support to states to maximize coverage gains as they implement key provisions of ACA. The program is managed by the Woodrow Wilson School of Public and International Affairs at Princeton University.