Eligibility Decision Consistency
The ACA requires consistent determination decisions regardless of the application method or entry point into the integrated eligibility and enrollment system.
*Milestone details:
*Full name: Establish structures or processes to promote consistency in eligibility, enrollment and retention decisions across application sites and methods.
*Relevance to the ACA:
The ACA requires states to develop a simplified, streamlined application and renewal process for consumers. Regardless of where an application or renewal comes into the system, a consumer will receive an eligibility or renewal determination for the appropriate health subsidy program. This cross-functionality between multiple programs necessitates that states coordinate their eligibility and enrollment processes across all programs to allow for consistent, accurate decisions. Provisions relevant to consistent eligibility, enrollment and retention decisions:
§1413 – Required streamlining procedures for enrollment, including a single application form and data matching arrangements among state agencies.
§2201 – Required establishment of an enrollment website that allows comparisons of benefits, premiums, and cost-sharing across Medicaid, CHIP and Exchange plans, and enrollment in the appropriate program through one application.
-- Exchanges are required to screen for and enroll eligible applicants in Medicaid or CHIP.
-- Medicaid programs can establish agreements with an Exchange to make tax subsidy determinations.
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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
Data Warehouse Medicaid Decision Support System II is anticipated to increase revenues, constrain cots, streamline and decentralize program reporting by addition functionality that will enhance the ability to monitor the effectiveness of various business processes.
This project is currently in the design phase with an anticipated schedule timeline from 4/1/2007 through 7/30/2012.
District of Columbia
Deborah Bachrach presented on New York’s approach to coordinating enrollment between Medicaid and the health insurance exchange. She also identified key eligibility and coverage issues for the state.
Access the presentation here:
http://www.statereforum.org/sites/default/files/ny_bachrach_elig.pdf
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
This presentation discusses the impact of the ACA on Medicaid, identifies implementation priorities, potential challenges, and impending decisions for the state’s Medicaid program, including operational challenges timing issues and transforming the eligibility process.
Access the presentation here:
http://www.statereforum.org/sites/default/files/eligibility_transformati...