Agency Authority for Eligibility
The ACA’s requirements for simplification and integration of Medicaid, CHIP and Exchange subsidy eligibility determinations necessitate an examination of roles that each program and administering and implementing agencies will play in newly designed systems.
*Milestone details:
*Full name: Decide state agency, county, Exchange and other parties’ responsibilities for eligibility determinations.
*Relevance to the ACA:
With ACA changes in Medicaid and CHIP eligibility determination, new Exchange tax subsidy determinations, and the requirement that these processes be integrated, states will need to determine the most effective, complementary roles for relevant agencies and entities in these processes. With a state level Exchange, and with more technology enabled eligibility determinations, greater centralization of many eligibility and enrollment functions will be possible and may be preferable in achieving streamlined eligibility determinations required under the ACA. Provisions relevant to responsibility for eligibility determinations include:
§1411 – Eligibility determination procedures for the Exchange and federal tax credits.
§1413 – Requirement that individuals found eligible for Medicaid or CHIP through an Exchange are enrolled accordingly.
§2201 – Requirements about screening and enrollment into Medicaid, CHIP and Exchanges.
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California
Hello All: Not sure if this is the correct place to post these questions, but I was wondering if folks have insights on the following:
1. What policies is your state developing in regards to eligibility determinations for public and exchange coverage? For example, is your state opting to let the Exchange determine eligibility for ALL programs or have a two phase system (exchange staff--exchange coverage, state agency-Medi-cal).
2. Has your state developed materials articulating how eligibility will be determined by each/ both agencies (Exchange and Medicaid agencies) and necessary agency coordination?
Any help would be greatly appreciated!
District of Columbia
Hi Fatima- Thanks for your questions. I would encourage other states to chime in with additional information, but here are some resources we have on State Refor(u)m to get you started:
Rhode Island’s eligibility and enrollment system, will integrate eligibility, enrollment and other functions for Medicaid, the exchange and additional human services programs. You can find their RFP here: http://www.statereforum.org/system/files/ri_eligibility_rfp.pdf
Washington’s current system will continue handling the initial enrollment transactions of Medicaid and CHIP members to the state’s Medicaid managed information system, and will soon serve as the eligibility service for the Exchange. Here is their RFP: http://www.statereforum.org/shinecomments/view_document_link/9320?ref=ht....
Maryland will establish a single IT infrastructure to evaluate eligibility for Exchange plans, Medicaid, Maryland Children’s Health Program (MCHP), and advance premium tax credits and cost-sharing reductions. The State may eventually integrate eligibility determinations for other human services programs into the HIX- more information is in this RFP: http://www.statereforum.org/sites/default/files/support_maryland_health_....
In Vermont, the individual exchange’s eligibility and enrollment system will be integrated seamlessly with Medicaid and other state-level programs. It will also administer premium tax credits and cost sharing reductions, facilitate free choice vouchers, and verify if individuals have access to affordable and quality employer-sponsored insurance. You can find more in “A Roadmap to Exchange Design in Vermont”: http://dvha.vermont.gov/administration/hbe-roadmap-to-exchange-design-03....
Connecticut
As of 6/30/10, Medicaid for Low-Income Adults (as well as Title 19) is administered directly by the Connecticut Department of Social Services. This is a change from the SAGA medical program, which was coordinated by the Community Health Network of CT for the Department of Social Services
California
This report, produced by the New York Department of Health, describes the state’s plan to transition the current locally-based administration of its Medicaid program, to a state-based administration system. The report broadly outlines how the state plans to accomplish this transition by the April 1, 2016 target date set by state legislation enacted in June. Access the report here: http://www.statereforum.org/sites/default/files/ny_adminreport2010.pdf
District of Columbia
Check out the legislation for New York’s plan to transition social service programs, including Medicaid, from a local- to a state-based administration system. The relevant language is found in S. 6608 on page 73, the 2010 New York state budget legislation.
http://assembly.state.ny.us/leg/?sh=printbill&bn=A09708&term=2009
District of Columbia
Download another great resource from New York about the shift from county to state-based Medicaid administration.
California
This report discusses a number of goals related to eligibility and enrollment.
Access the report:
http://www.statereforum.org/sites/default/files/md_finalreportentryworkg...
District of Columbia
The Iowa Legislative Health Care Coverage Commission presented 18 recommendations to General Assembly regarding implementation of the ACA. Highlights include planning for a new eligibility system to support Medicaid, CHIP, implementing a number of cost-containment strategies, and establishing an operational insurance information exchange by July 1, 2011.
Access the presentation here:
http://www.statereforum.org/sites/default/files/final_2010_comm_recommen...
District of Columbia
This report details the activities of the Converage Expansions for Iowa Care, Medicaid, and High Risk Pools Workgroup of the Legislative Health Care Comission to date, including the meetings held over the course of the year. It also includes recommendations made by the group, including many on Medicaid eligibility, IT systems, and the integration between the exchange and Medicaid.
Access the report here:
http://www.statereforum.org/sites/default/files/ia_care_expansion_workgr...