ACA Now

Implementation Status

2012

CMS implemented a final regulation in March 2012 outlining guidance in this area.

2013

In a related event, note that on January 3, 2013, the President signed into law the American Taxpayer Relief Act (ATRA), which included a provision that extends the Medicaid and CHIP Express Lane Eligibility (ELE) option through September 30, 2014.

CMS has since provided additional details regarding implementation of this provision in a proposed rule (and corresponding informational bulletin) released on January 14, 2013.

On January 28, 2013, CMS issued an information collection soliciting comments on changes the agency made to the individual application for streamlined enrollment through the Exchange, Medicaid, and CHIP.  These changes are denoted within the revised CMS-10440 form.  Comments on the revised application were due February 28.  CMS held webinars on the draft ACA streamlined application for health insurance on February 8 and 11.

On February 20, 2013, the OIG released a new report in which it examined the extent to which states intended to streamline eligibility and enrollment under Medicaid, CHIP, and the Exchange pursuant to the requirements set forth under this provision of the law.

During MACPAC’s February 13, 2013 meeting, the Commission voted to codify the 12-month continuous eligibility (CE) options in Medicaid and CHIP.  A copy of the MACPAC agenda is available here.

On March 14, 2013, House Energy & Commerce Committee GOP members wrote to HHS questioning the burden associated with the streamlined application process called for under the ACA, including for the purpose of insurance affordability programs.

On April 25, 2013, CMS issued a subsequent round of FAQs to address ongoing questions regarding ACA implementation, including those pertaining to: (1) the availability of the 75% federal match for maintenance and operations; (2) systems issues regarding communication between the Federally-Facilitated Marketplace (FFEs) and Medicaid/CHIP; and (3) further policy guidance regarding the use of section 1115 demonstrations.

On April 30, 2013, CCIIO released a single, simplified application for use by individuals beginning on October 1, 2013 to apply for health coverage under the Exchange (including premium subsidies), Medicaid, and CHIP.  The individual short form is available here; the family form, here; and the individual without financial assistance form, here. A CMS press release on the shortened, streamlined forms is available here.

On June 18, CMS released new guidance on state alternative applications for health coverage.  Recall that on April 30, 2013, CMS released the model application for coverage through the Exchanges and insurance affordability programs.  State-based Exchanges, as well as Medicaid and CHIP agencies, may choose to use the model single, streamlined application, or may develop an alternative application that is approved by CMS.  In states utilizing the Federally-facilitated Exchange (FFE), the Medicaid or CHIP agency may develop an alternative application, but the agency must still be able to accept and process the paper version of the model application if an applicant for coverage submits it.  This guidance is intended to provide background on the development, review and approval of alternative applications – including an outline of the parameters for creating an alternative application and areas where approval of modifications to the model application is not needed.

 On July 5, CMS issued a final rule implementing a number of ACA Medicaid eligibility, benefit and premium and cost sharing provisions, among others related to Exchanges, while explicitly noting a focus only on those “most critical for implementation” by January 1, 2014, and thus deferring the finalization of other proposals from a January 22, 2013, proposed rule – such as Exchange eligibility appeals, proposed CHIPRA provisions, Exchange certified application counselors and coordination of SHOPs with individual market Exchanges – to future rule-making. A CMS press release is available here.  Please also see CMS’ July 5 informational bulletin regarding related IT changes – i.e., Medicaid Information Technology Architecture (MITA) Draft Eligibility and Enrollment Supplement, Version 3.0 – as a result of certain Medicaid eligibility requirements resulting from the ACA.

Also, in a related event, on July 12, 2013, SAMHSA announced two new Challenges under which it will provide up to $100,000 in collective prizes for communications-related methodologies and materials to reduce enrollee “churn,” which may stem from eligibility-related changes or other breaks in coverage that SAMHSA notes have a “disproportionate impact” on individuals with behavioral health conditions, including enrollees who are Medicaid-eligible due to a disability.  Submissions are due by August 31, 2013.

Note that on June 28, 2013, House Ways & Means Committee GOP leaders wrote to HHS delineating their concerns regarding the Federal Data Services Hub to electronically share financial and non-financial information for purposes of determining eligibility under ACA coverage programs.

On August 9, 2013, CMS released FAQs related to these provisions of the law, with particular focus on telephonic applications; Medicaid and CHIP Eligibility Policy; and 75/25 Federal Matching Rate.  On August 15, CMS issued a letter to states (also see an accompanying bulletin), acknowledging the ACA-driven modifications in Medicaid and CHIP eligibility processes beginning in 2014 that will necessitate new approaches to measuring eligibility accuracy.  As such, CMS indicated it is implementing in place of the Payment Error Rate Measurement (PERM) and the Medicaid Eligibility Quality Control (MEQC) programs an “annual 50-state pilot program strategy with rapid feedback for improvement” beginning on January 1, 2014, for FYs 2014-16.

On August 13, the IRS released a final regulation regarding disclosure of certain return information to facilitate Health Insurance Exchanges’ and state agencies’ eligibility functions.  The IRS notes that disclosures of return information to HHS (including contractors) are “solely for purposes of, and to the extent necessary in” establishing Exchange eligibility, verifying advance premium tax credit and cost-sharing reduction amounts and assessing state program eligibility—specifically, for Medicaid, CHIP or a Basic Health Plan.

Note that October 2013 Medicaid and CHIP monthly application and eligibility data (as of December 3, 2013) are available here. The November 2013 Medicaid and CHIP monthly application and eligibility data (as of December 20, 2013) are available here. The December 2013 Medicaid and CHIP monthly application and eligibility data (as of January 22, 2014) are available here. In guidance released on November 29, 2013 regarding new flexibility extended to states to use account transfer flat files transmitted by the Federally Facilitated Marketplace (FFM) to enroll individuals in Medicaid and CHIP, addresses the interactions of this new flexibility with the mandatory transition to MAGI.

On December 11, 2013, HHS announced via the release of a monthly enrollment report that 258,497 people selected Marketplace plans in November, placing cumulative, Oct. 1 through Nov. 30 enrollments at 364,682. Additionally,  803,077 people have been “determined or assessed” by Marketplaces to be eligible for Medicaid or CHIP; HHS notes this represents 26% of those with processed eligibility determinations or assessments. HHS added that “1,747,608 (56%) of the 3,110,360 people whose eligibility determinations/assessments have been processed by the Marketplaces are either eligible for financial assistance through the Marketplaces, or have been determined or assessed eligible for Medicaid or CHIP.” Further details are available in this HHS press release. On a related note but specific to FFMs, on January 3, 2014, CMS issued guidance pertaining to certain enhancements made to account transfer flat files that can be used by states to enroll individuals who applied through the FFM into Medicaid and CHIP. See related guidance from December 2013 here.

2014

On a related note, P.L. 113-93, the Protecting Access to Medicare Act of 2014 (i.e., the “doc fix”), which was signed into law on April 1, contains a provision at section 203 that extends the Medicaid and CHIP Express Lane option for 12 months.

2015

On a related note, on Apr. 14, CMS issued a proposed rule codifying the permanent extension of the 90/10 federal match for approved Medicaid eligibility and enrollment (E&E) system upgrades. Absent this extension, state administrative expenditures for these IT upgrades – many of which are necessary pursuant to the broader E&E reforms called for under the ACA – would revert to the regular 50% federal match after Dec. 31, 2015. The rule also delineates revisions to the standards and conditions applicable to these systems to access the enhanced funding. Comments on the rule are due by Jun. 15.

On July 20, HHS and USDA issued joint guidance to states announcing a one-time extension by 3 additional years – through Dec. 31, 2018 – of the existing cost allocation waiver (pursuant to OMB Circular A-87). This specific cost-allocation exception allows states to continue to leverage funding efficiencies through further integration of state eligibility-determination systems. The guidance notes, for e.g., that “states experiencing unanticipated delays with the development of the Medicaid Modified Adjusted Gross Income (MAGI) functionality in their eligibility systems, procurement challenges, and other unforeseen barriers [will now be able] to complete that work and then effectively use the waiver extension to streamline their eligibility systems, improve access to health and human service programs, and maximize efficiency.”

On Sept. 23, CMS issued an informational bulletin announcing the publication of Minimum Acceptable Risk Standards for Exchanges (MARS-E) 2.0, which addresses certain ACA mandates and pertains to Exchanges, state Medicaid and CHIP agencies, and states administering the Basic Health Program (BHP).

On Sept. 28, CMS posted updated Medicaid and CHIP application, eligibility, and enrollment data, indicating that over 72 million individuals were enrolled in Medicaid and CHIP in July 2015.

2016

On Mar. 31, CMS issued a letter to states providing guidance on the enhanced federal match rate, and other federal match rates, for various activities related to Medicaid Information Technology (IT) in both Medicaid Management Information Systems (MMIS) and Medicaid Eligibility and Enrollment (E&E) Systems, including the use of Commercial Off-the-Shelf (COTS) software. Specifically, this guidance stipulates that the federal matching rates for Medicaid E&E systems are the same as those operative for the MMIS.

On July 25, CMS released an informational bulletin to provide states an overview of current regulations to ensure timely determination of eligibility and coordination across Medicaid, CHIP and the Federally Facilitated Marketplace.

On Aug. 25, HHS released a report showing that expanding Medicaid lowers Marketplace premiums by approximately 7 percent in states where expansion has occurred.  This analysis builds upon previous reports that have demonstrated Medicaid expansion’s positive impact on access to health coverage and care for individuals below 138 percent of the FPL, lowered hospital uncompensated care costs, and additional economic benefits.

On Sept. 30, CMS issued an informational bulletin, offering ways that states utilizing the federally-facilitated marketplace (FFM) can assist in enrollment for individuals when their eligibility is denied under Medicaid or CHIP. The bulletin also provides information to help state-based marketplaces improve their eligibility and enrollment coordination with Medicaid and CHIP programs.

2018

In early December, MACPAC published a synthesis report on a series of case studies examining how six states implemented changes in their Medicaid enrollment and renewal processes as a result of statutory changes in the ACA. MACPAC contracted with the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota School of Public Health to examine eligibility, enrollment, and renewal practices for beneficiaries whose income eligibility is determined based on MAGI in Arizona, Colorado, Florida, Idaho, New York, and North Carolina.  A broader report from SHADAC is available here. Our summary of MACPAC’s synthesis report is available here.