Form CMS-10398 #27 CMS-10398 #27 Part 2 of Modified Adjusted Gross Income (MAGI) Conversi

OMB Control Number 0938-1148

Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan

This MAGI Conversion Plan is being submitted to CMS by ___________(insert state name)

in accordance with the final FMAP rule published in the Federal Register April 2, 2013 (78 FR 19918) and under Section 1902(e)(14)(A) of the Social Security Act.

Purpose of Part 2 Income Conversions

Part 2 of the MAGI Conversion Plan includes income conversions that will be needed for FMAP claiming purposes in the new Medicaid adult group. States that wish to claim newly eligible and/or expansion state FMAP for enrollees in the adult group (42 CFR 435.119) must submit a State Plan Amendment (SPA) to CMS. States will use information from this document to complete the FMAP claiming SPA. It is highly recommended that states not expanding Medicaid in 2014 complete this document for all relevant eligibility groups so that necessary information will be available should the state implement a change in policy.

State Options for Part 2 MAGI Conversions

In its December 28, 2012 State Health Officials’ Letter, CMS laid out several MAGI conversion methodology choices for states. Choices that states made during Part 1 of the MAGI conversion process affect their options for this part (Part 2) of the MAGI Conversion Plan. In general, states must use the same method as they used in Part 1, with the exception that states that previously chose to do their own conversions may choose the Standardized MAGI Conversion Methodology with SIPP data for any groups that were not converted in Part 1. The state must provide an explanation of the reason for the change.

Information Provided to States for Part 2 MAGI Conversions

To facilitate the process of completing this document (Part 2 of the Income Conversion Plan), CMS is providing states with information summarized from available sources. CMS will provide each state with the following:

• A detailed list of the new conversions performed using SIPP; and

• A document titled “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.” This document combines information from the state’s approved Part 1 conversion plan and the new SIPP conversions performed, which together comprise the information that states will need to:

  • identify the relevant standards,

  • perform the conversions (for those states not using the SIPP conversions),

  • submit this document (Part 2 of the MAGI Conversion Plan) and

  • submit their FMAP claiming State Plan Amendments.

Populating the Relevant Standards in an FMAP Claiming SPA

The information that your state submits, and that CMS approves in this document (Part 2 of the MAGI Conversion Plan), will be recorded in the FMAP Claiming SPA. In the SPA states will provide the converted income standards for each relevant population group.

• For states using Option 1 (the Standard Method with SIPP data), the information to supply in your SPA appears in column C in the sheet titled “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.”

• For states using Option 2 (the Standard Method with state data or an alternative method), the information to supply in your SPA appears in column G in Table 1 of this document.

SECTION 1

Instructions

1. Please indicate the MAGI conversion method chosen by your state and follow the appropriate instructions below. (Reminder: this should be the same as the method your state chose for Part 1 of your Conversion Plan.)

Option 1 – Standardized Methodology with SIPP data

Option 2 – State Data (Standardized Method or Alternative Method): this includes states that chose to do their own conversions for Part 1 and choose to use SIPP data for eligibility groups that were not previously converted.

Please follow the instructions below and submit this plan to [email protected]. This document (Conversion Plan Part 2) is due by November 15, 2013 or ten days after receipt of your state’s Part 2 SIPP conversion results, whichever is later.

Option 1

Review the sheet titled “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan” that was provided to you by CMS with your Part 2 conversion results. Indicate in step 2 below which option your state is choosing for time-limited disregards, if applicable. Submit Section 1 along with the sheet labeled “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan” to CMS as Part 2 of your MAGI conversion plan.

Option 2:

Complete Section 2 of this document. Your state may use a combination of State Data and SIPP data for this submission, but you will need to provide additional explanation. In Table 1, for values that you have previously converted and CMS has approved or for which you are using SIPP you may either insert the state data/SIPP values from the “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan” sheet or insert specific cross references to that sheet.0 Submit this document to CMS as Part 2 of your MAGI conversion plan.

2. Time-limited disregards:

Select the appropriate option below for how your state chooses to convert standards with time-limited disregards for Part 2 of your MAGI conversion plan:

Not applicable, no new conversions of standards with time-limited disregards.

Use highest converted standard

CMS-supplied conversions with weighting for time-limited disregards

State-calculated weights for time-limited disregards (provide a separate attachment detailing the eligibility groups to which this applies, the weights applied, the data used to derive the weights, the formula used to apply the weight, and the converted standard).

SECTION 2

Option 2

For States Using Standardized Methodology with State Data or Alternative Method with State Data

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

Name: Title: _________________________________

E-mail:___________________ Phone:_______________________________

Supplemental Information: In addition to the information provided in this document, 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, mean gross income, and number of individuals with positive net income, number with earned income, mean earned income, number with unearned income, and mean unearned income

• Data files used for conversion

• Annotated programming code used in the analysis

FMAP Claiming Conversions

For States Using

Standardized Methodology with State Data

Or

Alternative Method with State Data

Please fill out Table 1 below to provide CMS with information about how state data were used for FMAP-related conversions. Use the “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan” provided by CMS to identify which standards need to be converted. Column B contains the net standards as of December 1, 2009 for each group.

Alternative Method States: Does the information you supplied about your alternative method in Part 1 of your state’s MAGI Conversion Plan also apply to the conversions in Part 2 (summary of method and data source, differences from standardized method, equations, description of how fixed dollar standards are converted, and description of how the method meets the criteria specified in the December 28, 2012 State Health Officials’ Letter on MAGI conversion)?

• Yes

• No: Please attach a separate explanation of how the method for FMAP conversion differs and why the changes to the method were made.

Instructions for Table 1:

Population group: The population groups listed in column A are the groups that are relevant for FMAP claiming. Special instructions for children ages 19-20: this conversion is only needed for FMAP claiming if your state covered the entire population of children; if coverage was limited to specific groups of children 19/20 (e.g., foster children), then you do not need to convert this group for FMAP claiming purposes. If a conversion is needed for the children age 19-20 group, please indicate in Column A which age limit (19 or 20) was applicable in your state as of December 1, 2009.

SIPP results used: In column B, if your state is using SIPP results for any groups, please mark yes in column B of Table 1 and provide the converted standard from those results. Please list the group below (e.g., parents) and an explanation of why the SIPP results are being used for this eligibility group (e.g., state data unavailable). Also, for groups that have time-limited disregards, if the state chooses to provide its own weighting, please provide the state-specific weighting strategy that was used to derive the converted standard. The explanation of the weighting strategy should include the percent assumed to have time limited disregards and the data on which this calculation was based (e.g., 15%: based on analysis of state data for those enrolled in the 1931 group in CY 2012). 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 even if the values are different (i.e., the state had a different standard in 2009 than in 2013).

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Time period: In column C, 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: In column D, mark yes or no. If yes (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: In column E, specify the net standard that was converted for each eligibility group. This can be located in column B of the document titled “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.”

Income band used in conversion: In column F, specify the income band that was used in conversion. This band should reflect the net standard minus 25 percentage points of FPL (or FBR if relevant).¹ 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 or FBR)¹ for each family size. ² For states using an alternative method, this column should only be filled out if it is applicable (e.g., if the marginal approach was used).

Converted standard: Fill in the converted standard that resulted from your calculations in column G. If your state is using SIPP results for any group in Table 1, this information can be found in column C of the document titled “Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan.” The information in column G will be the values you will use for your FMAP Claiming State Plan Amendment. For the non-institutionalized disabled adult group, indicate in column G whether you used the average or the median disregard from the relevant income band for conversion.¹

Table 1

Part 2 of MAGI Conversion Plan Using State Data

	Population Group	SIPP results used? (Yes/No)	Time Period selected	Sampling (Yes/No)	Net Income Standard	Income band used in conversion*	Converted Standard
	A	B	C	D	E	F	G
Conversions for FMAP Claiming
1	Parents/Caretaker Relatives (Expand number of rows for family size as needed for larger family size standards defined by the state)				% 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_______	% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______
2	Non-institutionalized disabled adults				% FPL ___________ % SSI FBR ___ or Dollar Standards Single_________ Couple________	%FPL __________ % SSI FBR _____ or Dollar Standards Single_________ Couple________	% FPL ___________ % SSI FBR _____ or Dollar Standards Single_________ Couple________ Conversion based on: __ Average disregard __ Median disregard
3	Institutionalized disabled adults (This is a gross income category: fill in column G only)						% FPL ___________ % SSI FBR _____ or Dollar Standards Single_________ Couple________
4	Children age 19 and/or 20 Specify age limit as of 12/1/09 (19 or 20): ________________				% 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_______	% FPL ___________ or Fixed dollar standards Family size 1_____________ 2______________ 3______________ 4______________ 5______________ 6______________ 7______________ Add-on for additional family members if relevant_______
5	Childless Adults				% FPL ___________	% FPL ___________	% FPL ___________

*Alternative method states: only fill out column F if applicable.

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 See “Frequently Asked Questions About MAGI Conversions for FMAP Claiming” for an explanation. Available at http://www.shadac.org/content/state-resources-converting-medicaid-eligibility-groups-magi.

2 See page 14 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.