Overview of Medicaid/CHIP (Children’s Health Insurance Program) Periodic Data Matching (PDM)
The Medicaid/CHIP PDM process involves yearly data checks by the Marketplace to identify consumers that are enrolled in Medicaid or CHIP who also have Marketplace coverage with subsidies (APTC/CSRs), to ensure proper eligibility and compliance.
Purpose and Functionality of Medicaid/CHIP PDM
The process aims to verify dual enrollment status and notify consumers to update or end their Exchange coverage with APTC/CSRs if enrolled in Medicaid or CHIP that counts as qualifying coverage.
Conducted at least twice per year starting January 1, 2021, per federal regulations.
Uses existing Non-Employer Sponsored Insurance (Non-ESI) MEC check service
Notifies consumers via initial warning notices and final notices.
Consumers have 30 days to respond to initial notices.
If no action is taken, APTC/CSRs are terminated, and consumers are informed they will pay full cost.
Notices are sent by mail and/or posted to My Account.
Final notices specify the date coverage without APTC/CSRs begins and instruct consumers to notify Medicaid/CHIP (Children’s Health Insurance Program) if they wish to remain in Exchange coverage without assistance.
Qualifying Medicaid and CHIP Coverage Types
Most Medicaid and CHIP coverage are considered qualifying, except some Medicaid forms covering limited benefits like emergency care, family planning, or pregnancy-related services.
Most Medicaid is qualifying; limited-benefit Medicaid is not.
Most CHIP coverage is qualifying.
For detailed qualifying coverage, visit healthcare.gov link provided.
Frequency and Implementation of PDM Checks
The marketplace is required to perform Medicaid/CHIP PDM at least twice annually.
Conducted during the coverage year based on previous round evaluations.
Uses existing data verification technology, minimizing additional state burden.
Checks enrollment data, not eligibility data.
Impact on Consumer Eligibility and Coverage
Consumers enrolled in Medicaid or CHIP are ineligible for APTC/CSRs.
If identified as dually enrolled, consumers are notified to end APTC/CSR coverage.
Consumers can keep their ACA coverage if they prefer, but without a subsidy (APTC/CSRs).
Consumers must notify Medicaid/CHIP of their Exchange enrollment if they choose to remain in Exchange coverage.
If Medicaid/CHIP coverage does not count as qualifying, consumers may still remain in Exchange with APTC/CSRs if otherwise eligible.
Consumers eligible for medically-needy Medicaid with a spend down do not need to end their Exchange coverage.
If consumers believe they are not enrolled in Medicaid or CHIP (Children’s Health Insurance Program), they should verify with their state agency and update their application accordingly.
Consumer Notices and Communication
Consumers are informed through initial warning notices titled “Warning: Members of your household may lose financial help for their Marketplace coverage” and final notices titled “IMPORTANT: Members of your household are still enrolled in a Marketplace plan but will no longer get financial help for it.”
Notices list dually-enrolled consumers and provide instructions to update or end coverage.
Notices include deadlines and contact information for Medicaid/CHIP and the Exchange.
Notices also advise consumers on how to appeal if they disagree with the termination.
Data Matching and Issue Resolution
The process does not involve checks for dual enrollment with Medicare that counts as qualifying coverage.
Consumers can experience data matching issues (DMI) if the Exchange cannot verify information.
Consumers must submit documentation within 90 days to resolve DMI.
If no documentation is provided, APTC/CSRs are terminated, but consumers can remain in full-cost coverage.
Consumers can appeal the decision within 90 days of the final notice.
The process does not include retroactive termination; consumers are advised to end coverage immediately if eligible for Medicaid or CHIP.
Additional Consumer Guidance and Responsibilities
Consumers should actively report changes in circumstances to Medicaid/CHIP and the Exchange.
They must notify Medicaid/CHIP of material changes affecting eligibility.
Consumers should contact their state agency if they believe they are enrolled in Medicaid or CHIP but have not received confirmation.
Consumers enrolled in Medicaid or CHIP should update their application if they wish to remain in Exchange coverage without APTC/CSRs.
Consumers are responsible for ending their Exchange coverage if they become eligible for Medicaid or CHIP that counts as qualifying coverage.
Consumers can appeal the Exchange’s eligibility decisions within 90 days of the final notice.
Coordination of benefits applies during dual enrollment, with Medicaid remaining the payer of last resort.
The process does not detect dual enrollment with Medicare that counts as qualifying coverage; that is addressed separately through Medicare PDM.
Transition from Medicaid/CHIP and Exchange Coverage to Medicare
Consumers dually enrolled in Medicaid or CHIP and Exchange coverage with APTC/CSRs who will soon turn 65 and qualify for Medicare should follow specific steps to update their coverage and enroll in Medicare to avoid penalties. -
Consumers should visit: healthcare.gov/medicaid-chip/cancelling-marketplace-plan/ or contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) to cancel their Exchange coverage.
Those turning 65 should enroll in Medicare as soon as possible.
Consumers receiving Social Security benefits at least 4 months before 65 are automatically enrolled in premium-free Medicare Part A and Part B starting the month they turn 65.
Consumers not receiving Social Security benefits should sign up during the 7-month Initial Enrollment Period (3 months before, the month of, and 3 months after turning 65).
Delaying Medicare Part A or B enrollment may result in late penalties and higher premiums.
A limited-time "equitable relief" was available for certain consumers enrolled on or before June 30, 2020, allowing enrollment in Medicare Part B without penalties if eligibility criteria were met by that date.
Resources
For more details, refer to CMS and Medicare.gov resources.
Medicare enrollees with limited income/resources or needing nursing/personal care may qualify for extra help from Medicaid.
For additional information, visit Medicare.gov and Medicaid resources.
Additional Resources
If you have any questions please contact Producer Support. Producer Support is available by phone at (866) 568-9649 , by email at [email protected] , or by chat directly from your MyMFG account.