1. Updated: DMAS TN-11 Effective 01/01/2019
Gap-Filling Rules
DMAS TN-8 Effective 04/01/2018
Updated: DMAS TN-11 Effective 01/01/2019

2. Acronyms Used in This Training
APTC: Advance Premium Tax Credit
CHIP: Children’s Health Insurance Plan
FAMIS: Family Access to Medical Insurance Security
FPL: Federal Poverty Limit
HIM: Health Insurance Marketplace
MAGI: Modified Adjusted Gross Income
Policy Reference: M – Gap Filling Rule Evaluation

3. The Gap-Filling Rule
A coverage gap occurs when the difference in APTC and Medicaid/FAMIS eligibility rules creates a situation in which an applicant is financially ineligible for both the APTC and Medicaid or FAMIS.
If the individual’s income using APTC MAGI rules at the HIM is under 100% FPL, they cannot receive coverage and are sent to the state for a Medicaid/FAMIS evaluation.
The individual’s eligibility for Medicaid/FAMIS is determined at the state level using Medicaid MAGI rules. When income is over the limit for Medicaid/FAMIS, the gap-filling rule is applied to help mitigate the coverage gap and potentially enroll an individual in Medicaid.

4. APTC
The APTC is a tax credit that an individual or family with taxable income of at least 100% FPL but no more than 400% FPL can take in advance to lower their monthly health insurance premium. Eligibility for the APTC is determined by the HIM using APTC MAGI rules for tax-filer households. Projected annual household income, rather than monthly income, is evaluated.
If the household's income is less than 100% FPL the household members are not eligible for APTC and the application is sent to the state for an evaluation for Medicaid/CHIP (FAMIS).
An individual does not have to apply at the HIM first to be evaluated under the gap-filling rule.

5. When to Use the Gap-Filling Rule
States are required to use household income (as calculated by the federal HIM for the APTC eligibility determination) to determine eligibility for Medicaid and FAMIS if both of the following conditions apply:
Current monthly household income, using Medicaid/FAMIS MAGI based methods is over the applicable income limit (including the 5% FPL disregard), and
Projected annual household income, using MAGI methods applied by the HIM for the purposes of APTC eligibility, is below 100% FPL (i.e. the lower income threshold for APTC eligibility). See M04, Appendix 1.
This required evaluation is referred to as the gap-filling rule. The gap-filling rule only applies to tax filer households (including dependents that meet a tax filing exception) as APTC methodology does not apply to the non-filer household.
Applying the gap-filling rule will not automatically be used for future eligibility determinations/renewals since tax dependency status may have changed.
Change: used to say dependent, now is tax filing household.

6. Application of the Gap-Filling Rule
This rule will be used for any MAGI covered group where the individual is over income using point in time income calculations.
Married couples that file separately do not meet the requirements for the gap-filling rule as they are not eligible for APTC.
If the child is over income for Medicaid, income eligible for FAMIS but has health insurance then they are still ineligible for the gap-filling rule.
This rule does not establish a special eligibility group; the individual must meet a covered group and all non-financial criteria.
If the individual is over the income limit using the gap-filling rule methodology, they must be offered the opportunity to be evaluated for and placed on a spenddown, if the individual meets a MN covered group.
Change: used to be only the tax dependent that met the exception, now for any member of the filling HH who is over income using point in time income determination; also if applicable since this could be applicable for adults.

7. Gap-Filling Rule: Household Income Calculation
Under the gap-filling rule, financial eligibility is determined using household income as calculated by the federal HIM for APTC purposes. Therefore the household composition for the gap-filling rule is the same as the APTC household which consists of the tax filer, their jointly filing spouse, and any tax dependents.
Financial eligibility for the APTC is based on annual income for the calendar year in which benefits are sought. This means that the individual’s prior income, or lack of income, for the calendar year, is included in the calculation of financial eligibility. While an individual may be over for MAGI Medicaid/FAMIS based on current monthly income, they may be eligible using the gap-filling rule and annual calendar income as used for APTC eligibility.
Agencies will need to verify past months of income (or lack of income), as well as project future months of income for the calendar year in order to calculate the annual income for the gap-filling rule.

8. Gap-Filling Rule: Income Calculations
Annual income is used for determining financial eligibility for the calendar year in which benefits are sought.
Months where the individual received partial or no income are included in the evaluation.
Example: Patrick provides proof of monthly income from his employer from January through June of $120 for January through May and $80 for June. He is not currently employed. Therefore his income January through June is 120x5=600+80=$680 and the rest of the year is projected as $0 as he cannot anticipate any future employment.
Actual income is used unless the agency is calculating a month of income based on an employer’s statement.
Example: Robert is paid biweekly and provides paystubs for February of $200 and $400 so Robert’s income for February is $600 (actual income). Laurel provides an employer statement indicating she has been employed the entire year paid $10.00 an hour working 20 hours a week and paid weekly so her income is 10x20=200x4.3=$860 monthly.
Actual income for the months of the year that have already passed is added to projected income for the remainder of the year.

9. Gap-Filling Rule: Income Calculations
Agencies still must use electronic data source verification to the fullest extent before requesting information from the applicant or authorized representative.
Virginia Employment Commission (VEC) income data may be used to the extent that the verified income was earned in the calendar year in which benefits are sought.
Exception: Agencies cannot use the IRS Hub match as this source does not project income for the current calendar year.
Income that is listed in M B as countable for the Medicaid/FAMIS MAGI evaluation is also countable for the gap-filling evaluation. Additionally, the following income is counted for the gap-filling evaluation:
Payments made to American Indian/Alaska Natives as described in M B.5.
Scholarship and fellowship income, regardless of its intended use
Lump sum payments received in the calendar year for which benefits are sought are included in the annual income calculation.
VEC is an addition
Updated countable income based on policy updates

10. Business Process: Evaluation
If an individual’s eligibility results in MN, or a denial/closure for income, ask yourself the following questions to determine if you must evaluate the individual under the gap-filling rules:
Is the individual ineligible for Medicaid and FAMIS solely due to income?
If yes, continue.
If no, the individual is not eligible for the gap-filling rule evaluation.
Is the individual part of a tax filing household (including a tax dependent that met an exception)?
If yes, then the individual is eligible for the gap-filling rule evaluation. Continue the evaluation on the next slide for income.
Updates to include other covered groups
Note: A child’s eligibility will be evaluated in the following order – FAMIS Plus  Extended MA (if LIFC parent/caretaker-relative exists and went to Extended)  FAMIS  Gap-Filling Rules for Medicaid  MN

11. Business Process: Evaluation
Determine the household for the individual using the APTC rules (tax filer, jointly filing spouse, tax dependents).
Determine the annual income for the calendar year in which benefits are sought for the household. This includes prior month’s income (or lack of income) and projecting monthly income for the remaining calendar months.
Compare the annual income to the 100% FPL limit in M04, Appendix 1. Then compare the income to the covered group’s income limit, without the 5% disregard. If the individual’s income is below the limit and they meet all other covered group requirements, enroll directly in MMIS. If the individual’s income is over the limit, provide the opportunity to be evaluated and enrolled in a spenddown.
At the time of enrollment, change the renewal date to January of the
following year.
RCs will need to enroll individuals if they don’t already have an enrollee ID. We are working on steps to give consultants that process as well as a form for agencies to use to complete the demographic info RCs need to complete the enrollment.
Change: this would be applicable to LIFC vs. expansion
Renewal: You do have to change the renewal date in MMIS which could affect other’s eligibility; remember you have to look at other changes as well. They may be eligible using regular point in time rules at the next renewal before looking at gap filling rule.

12. Business Process: VaCMS
The IBP “MAGI Gap-Filling Rule” is available as the functionality does not exist at this time. Use the IBP in combination with this presentation to complete the full evaluation.
Any information used for the gap-filling rule evaluation and notices/correspondence sent must still be uploaded into VaCMS. The evaluation of eligibility should be documented under Case Comments.
If the individual is eligible using gap-filling rules, the enrollment will have to take place outside of VaCMS but the individual’s eligibility must be closed within VaCMS.
LDSS must keep track of all individuals under this evaluation for ongoing case maintenance. Changes in information may lead to an evaluation of eligibility not requiring the gap-filling rules.

13. Practice: Eligible for Gap-Filling Rule?
Determine if the following individuals should be evaluated using the gap-filling rules. Marital status is single unless otherwise stated.
Anita applies for her son, Charles (12). Anita is married to and living with Eric, Charles’ father; they file taxes separately and claim Charles as a tax dependent. Charles’ eligibility determination is MN due to excess income for Medicaid/FAMIS.
Rebecca (22), a tax payer, and her husband, George (23), and their tax dependent child Alisha (4) are in the home together, however Rebecca is the only one that applies. Her result is denied due to excess income.
Gloria applies for her granddaughter Eliza (5). Gloria files taxes and claims Eliza as a tax dependent. Eliza’s eligibility determination is MN due to excess income for Medicaid/FAMIS due to her SSA Auxiliary benefits.
No: Even though Charles meets a tax dependent exception as his parents file separately, they are married. This family does not meet ATPC rules.
Yes: Rebecca can be evaluated, we do not know if she is eligible for not yet only because we don’t have income details at this time.
Yes: Eliza can be evaluated, but remember that the HH will include Gloria as the tax filing rules must be used. (this is a changed answer)

14. Practice: Eligible for Gap-Filling Rule?
Determine if the following individuals should be evaluated using the gap-filling rules. Marital status is single unless otherwise stated.
Betty applies for her son, Xavier (8). Betty lives with Xavier’s father, Conner; they file taxes separately and Betty claims Xavier as a tax dependent. Xavier’s eligibility determination is MN due to excess income for Medicaid/FAMIS.
Nicholas applies for his daughter, Sabrina (2). Nicholas and Sabrina’s mother, Maria, live together. Maria does not file taxes but Nicholas does and claims Sabrina as a tax dependent. Sabrina’s eligibility determination is MN due to excess income for Medicaid/FAMIS.
Rebecca applies for her daughter, Penelope (16). Penelope’s father Lewis lives with Rebecca. Rebecca and Lewis file taxes separately and Lewis claims Penelope as a tax dependent. Penelope’s eligibility determination is MN due to excess income for Medicaid and is ineligible for FAMIS due to health insurance.
Yes: Since the unmarried parents live in the home and do not file jointly, the tax dependent meets an exception and since the dependent is over income for Medicaid/FAMIS, the gap-filling rule will be evaluated.
Yes: The same situation as #4 applies. It does not matter that both parents file taxes or not, but that the individual who is over income is part of a tax HH.
No: The individual must be ineligible for Medicaid an FAMIS solely due to income.

15. Putting It All Together: End to End Evaluation
Let’s look at Betty’s scenario (Example 4). We will use her situation to evaluate her son, Xavier, using the gap-filling rules.
Xavier’s household for gap-filling rules will be the tax filer, Betty, and Xavier. Conner is not included as he is not part of Betty’s tax household.
Betty’s annual income is verified through an employer statement as follows: She has been employed since 2016 with the same company with an annual salary of $36,000.
Since Betty’s annual income exceeds 100% FPL ($16,910 effective 01/2019) Xavier is not eligible using gap-filling rules. The agency must evaluate Xavier for MN coverage.

16. Putting It All Together: End to End Evaluation
Now let’s look at Nicholas’ scenario (Example 5). We will use his scenario to evaluate Sabrina’s eligibility.
Sabrina’s household for the gap-filling rules is Nicholas and Sabrina. Maria is not included as she is not part of Nicholas’ tax filing household, even though she is Sabrina’s mother.
Nicholas’ income is as follows: Nicholas was unemployed from January – June. He started a new job on July 2nd and provided the following paystubs: July 14th - $520.50, July 28th - $750.75; he applied in August and stated his July 28th paystub is representative of his ongoing biweekly income. Annual income for Nicholas is calculated as January – June $0, July $ (actual as paystubs provided, not because of partial month income), August-December $750.75x2.15=$ monthly for total annual income of $ The household’s annual income is below the income limit ($16,910) and Sabrina is eligible for Medicaid using gap-filling rules. She is enrolled as AC 091.

17. Putting It All Together: End to End Evaluation
Lastly, let’s look at Rebecca’s situation (2). Her tax filing HH is the same as her MAGI point in time HH, 3. She applies 11/01/19.
Rebecca’s income is $1100 monthly, verified through EV and she has been employed since George’s income is $ a month at his new job. The point in time determination is $ monthly which is over income.
Annual income verification shows Rebecca’s income as $1100 a month, and for George he worked Jan-Mar for a total of $1000, then was unemployed April-Sept. In October he started his new job where he made $1800 in October, then $2500 for November and is expected to make that ongoing. This means their annual income is $ which is under 100% FPL for a HH of 3, $21330.
Rebecca is over for LIFC, but is eligible as a MAGI Adult under AC 100.

18. Gap-Filling Rule: Combining System and Policy
Now that you’ve learned the policy, procedure in VaCMS, and reviewed determining eligibility, put it all together in the following steps to complete the evaluation:
Determine if the MN or denied/closed result is due to excess income for Medicaid/FAMIS and the individual is part of a tax filer household.
Determine the tax household and countable income.
Compare the household income to the 100% FPL. If the income is under 100% FPL, compare to the covered group’s income limit without the 5% disregard. If eligible, enroll in MMIS directly and close in VaCMS following the IBP; update the renewal date to January of the following year. If the income is over 100% FPL, continue the evaluation in VaCMS to evaluate as MN.
Changes for update in policy.

19. Gap-Filling Rule: Combining System and Policy
Continued:
Be sure to document the evaluation of eligibility within VaCMS as well as upload any information used to determine eligibility. Track the enrollment manually for ongoing case maintenance.
If the individual does not return the information needed to evaluate using the gap-filling rule, deny the application and continue the steps to evaluate for MN. Be sure to deny for over income but explain that eligibility could not be determined for the gap-filling rule because verifications were not received as well.

20. Ongoing Case Maintenance
A renewal of eligibility must be completed in January of the following year and annually thereafter. At the time of enrollment, change the renewal date to January of the following year. Evaluate the individual’s eligibility using Medicaid/FAMIS MAGI methodology before applying gap-filling methodology. A gap-filling evaluation may not be necessary for future eligibility determinations/renewals since tax dependency status and/or income may have changed.
Note: The automated ex parte process will flip these individuals’ Program Request from Yes to No before renewing via ex parte. If there are enrollees in MMIS only you will have to change the program request back to Yes and document if the individual should move back to FAMIS or Medicaid within VaCMS because the gap-filling rule will no longer be used.
Changes in policy

21. Contacts:
Jessica Annecchini, MA Consultant, Home Office: