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  • Final Rule on Certain ACA Provisions Addresses Medicaid, CHIP

    A final rule on provisions of the Affordable Care Act (ACA) will impact physical therapists (PTs) as providers of services under Medicaid and the Children's Health Insurance Program (CHIP).

    Provisions of the final rule include:

    • New Medicaid eligibility provisions
    • Changes related to electronic Medicaid and CHIP eligibility notices and delegation of appeals
    • Updates that streamline existing Medicaid eligibility rules
    • CHIP revisions related to the substitution of coverage to improve the coordination of CHIP coverage with other coverage
    • Amended requirements to ensure that most alternative benefit plan (ABP) packages include essential health benefits and meet certain other minimum standards
    • Implementation of specific rules for insurance exchanges related to authorized representatives, notices, and verification of eligibility for qualifying coverage in an eligible employer-sponsored plan
    • Updates that simplify the complex Medicaid premium and cost-sharing requirements

    In addition, the rule addresses ACA's new optional eligibility group for low-income adults aged 19 to 64. Effective January 1, 2014, states that implement this new eligibility group must provide medical assistance for these adults through an ABP, except that individuals in the new group who meet the exemption criteria can choose between ABP benchmark benefits as defined by the state under the ACA rules and ABP benchmark benefits defined as the state's approved Medicaid state plan. Adults not meeting exemption criteria must be provided the 10 mandatory benefits that the ACA deemed "essential health benefits," one of which includes rehabilitative and habilitative services.

    States that do not opt for Medicaid expansion to this new group will not have to provide ABPs to this population. However, states have the flexibility to define different benefit packages to meet the needs of disparate populations. For example, states retain flexibility to continue to offer optional benefits, such as outpatient physical therapy services, to their Medicaid beneficiaries.

    APTA will post a summary of this final rule on the APTA website soon.

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