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    Assessment vs. Determination: State Decisions on Coordinating Eligibility in a Federally Facilitated Marketplace

    With open enrollment underway, individuals and families are seeking out health insurance coverage available through health insurance marketplaces and state Medicaid programs. Since individuals can apply through either program, coordination of Medicaid eligibility decisions is taking place behind the scenes. States have the flexibility to decide on the details of how their Medicaid agency and marketplace will coordinate, whether the state has opted for a State-Based (SBM), State-Partnership (SPM), or Federally Facilitated Marketplace (FFM).

    Each state Medicaid agency has chosen whether the marketplace will only assess, or whether it will also determine Medicaid eligibility for individuals who apply through the marketplace. While SBMs are able to coordinate all of this within the state, SPMs and FFMs are in a situation where the Federal government must coordinate closely with state Medicaid agencies. There are two models a state may use:

    • Assessment model: the SPM or FFM makes an initial assessment of eligibility for Medicaid, and the state Medicaid agency makes the final Medicaid eligibility determination. Twenty-five SPM or FFM states have opted for this model as of October 1, 2013.
    • Determination model: the SPM or FFM makes the final Medicaid eligibility determination and transmits this determination to the state Medicaid agency. Eleven SPM or FFM states have opted for this model as of October 1, 2013.

    A new NASHP brief, written with support from the Robert Wood Johnson Foundation, lays out these options in more detail.

    Arizona’s Assessment Model

    Arizona’s Medicaid eligibility system is rules driven, highly automated and integrated with other social service programs such as the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). The assessment model maintains the state’s ability to connect individuals and families to other social services when they enroll in Medicaid. Given its unique location with five state borders and an international border, having the state make the final Medicaid determination also allows Arizona to continue to use current residency and income verification processes.

    West Virginia’s Determination Model

    West Virginia conducted a cost benefit analyses focused not only on the cost to the state, but also on the experience of the consumer in order to help the state make the decision on whether the FFM would assess or also determine Medicaid eligibility. The results of the report led the state to decide that the determination model would provide a simple, integrated process for consumers with minimal burden on state staff.

    Moving Forward

    Whether the SPM or FFM is assessing or determining Medicaid eligibility, individuals and families must be able to complete and submit a user-friendly application for all Insurance Affordability Programs (IAPs) online, via telephone, through the mail, or in-person to the SPM or FFM—or to any agency administering an IAP. State Medicaid agencies and marketplaces will need to coordinate closely to ensure that processes are streamlined, accurate and identify all eligible individuals. States will want to closely monitor the consumer experience under both models and make adjustments as needed to ensure individuals and families are enrolled in the appropriate health coverage programs.

    How is the FFM/SPM and Medicaid agency collaborating in your state in order to make eligibility determinations for new applicants? What model did your state choose and why? Let us know by posting a comment here.

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