Form CMS-10398 (#14) CMS-10398 (#14) 14 MAGI Conversion Plan

Modified Adjusted Gross Income (MAGI) Conversion Plan

This MAGI Conversion Plan is being submitted to CMS by ___________(insert state name) as required by Section 1902(e)(14)(E) of the Social Security Act, which requires each state to submit for approval the income eligibility thresholds for Medicaid and the Children’s Health Insurance Program (CHIP) proposed to be established using modified adjusted gross income (MAGI). As described in the December 28, 2012 State Health Officials’ Letter on Modified Adjusted Gross Income (MAGI) income conversion, states can choose among three options to convert net standards for Medicaid and CHIP to MAGI equivalent standards. ¹ The purpose of the MAGI Conversion Plan is to provide CMS with information about each state’s MAGI conversion methodology, as well as the data used and results of conversion. CMS will be reviewing the submitted materials and notifying the State with their approval or disapproval by June 15, 2013.

Eligibility and FMAP claiming conversions. States are required to submit information about their conversion methodology, data and results for income conversions related to eligibility and those required for FMAP claiming in accordance with CMS’ FMAP rule. For additional information about the FMAP rule, please see: https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-07599.pdf.

Note about Income Eligibility Conversions and State Plan Amendments: Converted income standards will be used to set maximum MAGI-equivalent standards for adults in 2014 and will be used as the actual income standard in effect for children through October 2019. States will use the state plan amendment (SPA) process to identify the minimum and maximum MAGI-equivalent standards and to select the state’s MAGI-based income standard for each eligibility group to which MAGI will apply in 2014. For adults for whom the Maintenance of Effort requirement expires in 2014, the selected income standard in the SPA will be anywhere between the minimum allowed and the maximum derived through the income conversion process.

Please indicate the MAGI conversion method chosen by your state and follow the appropriate directions:

• Option 1 – Standardized Methodology with SIPP data

Attach Excel spreadsheet with finalized SIPP results of eligibility and FMAP conversions to this cover page and submit to [email protected].

• Option 2 – Standardized Methodology with State data

Please follow the instructions below and submit this plan to [email protected].

• Option 3 – State proposed Alternative Method

Please follow the instructions below and submit this plan to [email protected].

	Part 1 – Conversions for Eligibility		Part 2 – Conversions for FMAP Claiming
	Pages to Complete	Due Date		Pages to Complete	Due Date
Standardized Methodology	Page 1	May 31, 2013		Page 1	August 1, 2013
Standardized Methodology with State Data	Page 3-10	April 30, 2013		Pages 13-18	August 1, 2013
Alternative Methodology	Page 3-12	April 30, 2013		Pages 13-18	August 1, 2013

,

Standardized Methodology with State Data Method

and

Alternative Method:

Please provide a state contact who can answer questions about the conversion plan, data, and methods:

Name: Title: _________________________________

E-mail:___________________Phone:_______________________________

Supplemental Information: In addition to the information provided in the attached MAGI Conversion Plan, during the review and approval process, CMS may determine that supplemental information regarding the income conversion results is necessary. If CMS determines that a supplemental review of these results is necessary, your state may be required to submit:

• Descriptive statistics of the data used. Such descriptive statistics could include for each eligibility group converted with state data:

  • Net income statistics and disregard statistics for the full population or sample and for the population used in conversion (e.g., the 25% band) including: Total N, Mean Net Income, Standard Deviation of Mean Net Income, Median Net Income, and Number of individuals with Positive Net Income

• Data files used for conversion

• Annotated programming code used in the analysis

PART 1: ELIGIBILITY CONVERSIONS- TABLE 1 – DUE APRIL 30, 2013

For States Using

Standardized Methodology with State Data

Or

Alternative Method

Please fill out Table 1 below to provide CMS with information about how state data were used for MAGI income conversion. All cells in rows for eligibility groups that do not have a converted income standard in your state (for example, if your state does not cover independent foster care adolescents or does not apply an income standard to this group) should be marked “N/A.”

Instructions for Table 1:

SIPP results used: Your state may have used SIPP results for converting some groups. For conversions based on SIPP, please mark yes in the first column of Table 1 and provide the converted standard from those results.² Please list the group below (e.g., pregnant women) and an explanation of why the SIPP results are being used for this eligibility group (e.g., data unavailable). Attach additional pages if necessary. Note that for groups that need to be converted both for eligibility and FMAP purposes (e.g,. childless adults) the same income conversion method/data source (i.e., SIPP or state data) must be used.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

For all conversions using state data, please provide the following information:

Time period-Specify the time period of data that was used, for example, June 2011-May 2012. If a time period other than 12 months was used, please explain why below and summarize the methods used to determine that the time period is unbiased. Attach additional pages if necessary: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Sampling: Please mark this column yes or no. If yes (in other words, the analysis did not include all records in the eligibility group), please provide a detailed explanation below of the sampling approach that was used (i.e., simple random sample, stratified sample, etc.). Please also provide information about the total population and the number of records sampled. Attach additional pages if necessary. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Net income standard- Please fill in the net standard that was converted for each eligibility group. This should reflect the bolded standard from the eligibility template that you developed with CMS. For conversions that were based on fixed dollar thresholds, please specify the net standard for each family size. You may use fewer or more family sizes than indicated in Table 1.

For 1115 demonstrations, please enter a row for each MAGI-included 1115 demonstration group, specifying whether its Medicaid or S-CHIP.

Income band used in conversion-This column is applicable only for the State Data method and should reflect the net standard minus 25 percentage points of FPL. For example, if the net standard was 120% FPL, the income band used in conversion would be 95% FPL to 120% FPL. For standards at or below 25% FPL, the income band will include all records—e.g., for a net standard of 18% FPL, the income band used in conversion should be 0-18% FPL. For conversions of fixed dollar thresholds , please specify the income band (expressed as a percentage of FPL) for each family size. ³

Converted standard for applicants-Please fill in the converted standard for applicants. Fixed dollar standards should be given in dollars for each family size.

Converted standard for beneficiaries (if relevant)- If your state applies different disregards based on whether someone is applying or being renewed for coverage, and you are doing a separate conversion for beneficiaries, please provide. Fixed dollar standards should be given in dollars for each family size.

Special note for premium payment groups: if your state charges premiums for any eligibility group, you will need to attach a separate sheet showing the MAGI Conversion Plan information requested for each income level used to determine premium payments.

Table 1

Coverage Category	SIPP Results used (Yes/No)	Time Period	Sampling (yes/no)	Net Income Standard	(For State Data Method Only) Income band used in conversion	Converted Standard for Applicants	Converted Standard for Beneficiaries (if relevant)
Parents and other caretaker relatives (mandatory under Section 1931)				% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL ___________ or % FPL by Family size (for groups with fixed dollar standards) 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______
Parents and other caretaker relatives (optional under 1902(a)(10)(A)(ii)(I)				% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL ___________ or % FPL by Family size (for groups with fixed dollar standards) 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______
Pregnant women, full benefits
Pregnant women, pregnancy only coverage
Children under age 1
Children ages 1 to 5
Children ages 6 to 18
M-CHIP optional targeted low-income children
Optional reasonable classifications of individuals under age 21
State adoption assistance
Independent foster care adolescents
Family planning services
Individuals needing TB-related services
Other Medicaid section 1115 demonstration (e.g., childless adults)
Separate CHIP Children
Separate CHIP Pregnant Women
Separate CHIP Unborn child option
AFDC payment standard 5/1/1988				Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL by family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______
AFDC payment standard 7/16/1996				Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	% FPL by family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______	Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______
Premium payment determination	PLEASE ATTACH A SEPARATE SHEET SHOWING REQUESTED INFORMATION FOR EACH RELEVANT INCOME LEVEL USED TO DETERMINE PREMIUM PAYMENTS
Pre-CHIP Medicaid as of 3/31/97				< age 1________ 1-5____________ 6-13___________ 14-18___________	< age 1________ 1-5____________ 6-13___________ 14-18___________	< age 1________ 1-5____________ 6-13___________ 14-18___________	< age 1________ 1-5____________ 6-13___________ 14-18___________

PART 1: ELIGIBILITY CONVERSIONS

Alternative Method, additional information

Please provide a summary of the alternative method and data source or sources used for income conversion, including how the method differs from the Standardized MAGI Conversion Methodology specified in the December 28, 2012 State Health Officials’ Letter on Modified Adjusted Gross Income (MAGI) Income Conversion. Please include equations showing how the method is applied mathematically and a description of how fixed dollar standards were converted, if relevant. Attach additional pages if necessary. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide a description below of how your method meets the criteria specified in the December 28, 2012 State Health Officials’ Letter on Modified Adjusted Gross Income (MAGI) Conversion: unbiased, accuracy, precision, and data quality. Attach additional pages if necessary. More detailed information about these criteria is available in the ASPE issue brief Modified Adjusted Gross Income (MAGI) Income Conversion Methodologies. ⁴

Unbiased: Across all eligibility categories, the method does not systematically increase or decrease the number of eligible individuals within a given eligibility group or systematically increase or decrease the costs to states.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Accuracy: To the extent possible, the method minimizes changes in eligibility status by minimizing losses and gains in eligibility for a given category of coverage.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Precision: The converted standard must be stable and repeatable. In other words, if the methodology to arrive at the converted standard were repeated, it would arrive at the same result. For example, if a sampling methodology is used, the sample size must be large enough to ensure that the conversion method, if calculated on another sample, would in general yield the same converted standard.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Data quality: The data used are representative of the income and disregards of the population so as not to bias the converted standard due to poor data quality. ________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PART 2: FMAP CONVERSIONS – DUE AUGUST 1, 2013

For States Using

Standardized Methodology with State Data

Or

Alternative Method

Please fill out Table 2 below to provide CMS with information about how state data were used for FMAP related conversions. If your state did not cover a certain eligibility group on December 1, 2009, all cells in that row should be marked “N/A.” All states must fill out relevant conversions under “MAGI groups relevant for FMAP” and “optional ABD groups.” 209(b) states must also fill out information for the relevant mandatory groups listed at the end of the table (i.e., if the state applied a disregard on December 1, 2009 that varied from the standard SSI-related methodology disregards).

Instructions for Table 2: This template assumes that the information about sampling and time period selection you provided for eligibility conversions in Part 1 of this plan also apply to the FMAP conversions in part 2. If not, please attach a separate explanation of how and why they differ.

SIPP results used: Your state may have used SIPP results for converting some groups. For conversions based on SIPP, please mark yes in the first column of Table 1 and provide the converted standard from those results.⁵ Please list the group below (e.g., TWWIIA basic group) and an explanation of why the SIPP results are being used for this eligibility group (e.g., state data unavailable). Attach additional pages if necessary. Note that for groups that need to be converted both for eligibility and FMAP purposes (e.g,. childless adults) the same income conversion method/data source (i.e., SIPP or state data) must be used.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Effective income standard: For MAGI groups relevant to FMAP claiming, in most cases this will be the effective income standard your state provided in Part 1. However, if the effective income standard was different on 12/1/2009, that standard should be listed here. For ABD groups, this standard will be the bolded effective income standard from the ABD template you completed with CMS. Please provide this information in % of FBR or in fixed dollar state supplement payments as relevant, and for different family sizes as applicable.

Converted standard for applicants-Please fill in the converted standard for applicants.

Converted standard for beneficiaries (if relevant)- If your state applies different disregards based on whether someone is applying or being renewed for coverage, and you are doing a separate conversion for beneficiaries, please provide. Fixed dollar standards should be given in dollars for each family size.

Table 2

Eligibility Group	SIPP Results used (Yes/No)	Time Period (e.g., June 2011-May 2012)	Effective Income Standard	Converted Standard for Applicants	Converted Standard for Beneficiaries (if relevant)
MAGI groups relevant for FMAP claiming
Parents and other caretaker relatives
Other Medicaid section 1115 demonstration (e.g., childless adults)
Optional reasonable classifications of individuals under age 21
Optional ABD Groups
Aged, blind and disabled individuals financially eligible for SSI cash assistance
Aged, blind or disabled individuals receiving only optional state supplements in 1634 or certain SSI criteria states Aged, blind, or disabled individuals who would be financially eligible for SSI cash assistance if they were institutionalized
Institutionalized individuals eligible under a special income level
HCBS waiver enrollees eligible under institutional rules
HCBS waiver enrollees eligible under institutional rules
Individuals receiving hospice care
Aged, blind, or disabled poverty level group
Aged, blind, or disabled individuals receiving only optional state supplements in 209(b) or certain SSI criteria states
Work Incentives Eligibility Group (BBA group)
TWWIIA Basic Group
TWWIIA Medical Improvement group
Family Opportunity Act group
Katie Beckett Group (TEFRA children)
PACE group
Medically Needy
Mandatory Groups (209(b) states only)
Aged, blind and disabled individuals in 209(b) states
Disabled Adult children
Early widows and widowers
Pickle group

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 . The time required to complete this information collection is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

1 SHO letter available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO12003.pdf

2 If SIPP results include conversions for applicants and beneficiaries, both should be included.

3 See page 15 of How States Can Implement the Standardized Modified Adjusted Gross Income (MAGI) Conversion Methodology from State Medicaid and CHIP Data for more information on converting fixed dollar standards to FPL. http://aspe.hhs.gov/health/reports/2013/MAGIHowTo/rb.cfm.

4 See http://www.shadac.org/files/2.%20ASPE%20Brief%20-%20MAGI%20Income%20Conversion%20Methodologies%20(March%202013).pdf.

5 If SIPP results include conversions for applicants and beneficiaries, both should be included.

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