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and Tricia Brooks

For those of you who have been anxiously awaiting (and you can count us, too!) the release of the annual survey on Medicaid and CHIP, today is your lucky day.  In partnership with the Kaiser Commission on Medicaid and the Uninsured, we released "Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost Sharing Policies in Medicaid and CHIP" at a briefing today.

Probably not surprising to those who follow such things, but we found that eligibility held steady in nearly all states, with only two states reducing eligibility. And the two that did - they did so for low-income adults relying on limited exceptions to the stability protections (otherwise known as maintenance of effort provisions of the Affordable Care Act). It's very likely that without the stability protections, more states would have made cutbacks and far more children and families would be left without an affordable coverage option during these turbulent economic times.

A far more surprising finding was the fact that 29 states went beyond holding steady and improved coverage through targeted expansions and simplifications. Most of these changes centered around the greater use of technology to boost government efficiency and make it easier for people to enroll in coverage; actions that have a dual benefit of helping eligible children and families while also stretching scarce state administrative resources.

But perhaps the most striking finding is how quickly a large number of diverse states across the country are leaping at the opportunity to make sweeping changes to their decades-old eligibility systems. More than half of the states have already sought the enhanced federal funding to develop the latest technology that will both transform families' experience of applying for health care coverage and make government work better. And, with just three exceptions, the rest of the states are planning to move in that direction in 2012.

And all this in spite of the fact that in 2011, state budgets remained stressed due to dampened revenue growth and the mid-year expiration of the temporary increase in the federal matching rate. So while strained state budgets have taken a toll on administrative resources, states have sharpened their use of technology and streamlined their procedures to create more efficient programs, while also simplifying the steps for families to enroll in and renew coverage. These actions, in addition to the massive systems upgrades they've undertaken, have not only helped states deal with current pressures, but are also laying the groundwork for the coverage expansions and new enrollment requirements that will take effect in 2014.

And let's not forget that amid these ongoing pressures, the stability protections in the Affordable Care Act were central to the preservation of health care coverage last year. So even with a weak economic recovery that has been slow to add new jobs with access to employer-based insurance, Medicaid and CHIP continued to be key sources of coverage for children, and, in some cases, for their uninsured parents. A bit of good news to start the year!

[A parting note to those who like us, want to dig in on the nitty-gritty details - there are several new areas that we report on this year (such as the use of out-stationed state eligibility workers and enhanced functionality with online accounts) all of which can be found in the full report. Enjoy!]

By Beth Morrow, The Children's Partnership 

As all health advocates know, states face a daunting task in preparing to meet the demands of ACA implementation.  Building an eligibility, enrollment, and retention system is one of the first challenges involved in getting ready for state Exchanges' open enrollment period on Oct. 1, 2013.  Deploying such a system involves more than just building the technology.  The design and development of this technology will be driven by complex policy, process, and governance decisions that states are making now.  With aggressive implementation schedules, no state has the luxury of waiting before starting to design their system.

As California proceeds through this very consequential puzzle, The Children's Partnership has written a 40-page blueprint designed to assist in that process and make sure that consumers' interests are front and center as decisions are made.  Written by Dawn Horner and myself, Building A Consumer-Driven Eligibility, Enrollment, and Renewal System: Essential Design Features for Effective Health Reform in California lays out the essential design features that are required in any state for an effective enrollment system that meets federal expectations.  In California, this new system is being called CalHEERS (for California Healthcare Eligibility, Enrollment, and Retention System).

Broadly these essential design features are:

• Smart connections that allow consumers to apply for coverage through multiple doorways (whether online, by mail or phone, or in person) and receive consumer assistance -including live human assistance--as needed.
• Integrated eligibility criteria and processes that allow every consumer to apply using a single application for all programs, and to seamlessly move between programs as family circumstances change.
• Real-time, immediate, and ongoing enrollment that utilizes technology to obtain and verify data and eliminates unnecessary paper documentation.
• Easy navigation of coverage that allows consumers to pick their health plan, pay premiums, and update their account through a centralized system.

For each design feature, the report provides specific recommendations (some very detailed, some more general), summarized as a tear sheet in the Executive Summary.  A small sampling of the report's recommendations includes:

•  Establish accuracy and timeliness standards to guarantee quality of consumer assistance.

• Eliminate the three-month waiting period for children with employer coverage for Healthy Families (California's CHIP program).

•  Automatically transfer children from 101% to 138% FPL from Healthy Families to Medi-Cal (the state's Medicaid program) and provide support to maintain continuity of care.

• Integrate human service program enrollment into CalHEERS by the end of 2015, commencing with SNAP and TANF.

•  Establish a policy that finds "incompatibility" within an application only where the inconsistent data would have a "material" impact on eligibility - i.e., would change the outcome. 

• Design the premium payment function so that consumers receive one monthly bill for the whole family. 

Our new report provides a guide for action for California, to ensure that the state gets this right, right out of the gate.  And, while written to address California's specific concerns, this report can help any state move toward a first-class consumer experience that results in individuals getting the coverage and health care they need.

By Barbara Munoz, Voices for Utah Children

Although I am admittedly behind the curve a bit, I am proud to say I finally own a smart phone. The level of functionality of this "phone" (let's be honest, it's a tiny computer) is astounding. I can check my email, my Facebook account, send out a "tweet", purchase goods online, and even turn my phone into a flashlight! With so many people turning more and more to their phones and computers to complete numerous day to day transactions, we at Voices for Utah Children believed that surely all this fantastic technology could be used to help kids get and keep their health care coverage as well!

Last year, Voices for Utah Children approached the state to consider the idea of using electronic notification to alert clients that their CHIP premium was due. As many of you know, the problem of "churning" is a great concern. We are constantly seeking ways to make it easier for families to complete the renewal process, pay their premiums, and report changes that might affect their eligibility. We believed that if the state could alert clients about their CHIP premiums electronically, it would not only assist the families, but it could potentially save the state money as well. While the idea was initially met with some skepticism and resistance, to say the idea was eventually embraced with enthusiasm would be a great understatement.

Final approval came from CMS earlier this year for the State of Utah Department of Workforce Services to start giving clients the ability to "opt-in" to start receiving paperless correspondence. In additional to electronic notification, the state had begun working on an electronic case management system for client interaction called "myCase". The system build is still in progress, but it already has some pretty amazing features:

* Our governor, Gary Herbert, announced in a speech recently to the Heritage Foundation that through electronic correspondence the state will save over six million dollars in administrative and mailing costs.

* As of mid-July, the 100,000th client had enrolled in myCase.

* Over 525,000 notices have been viewed through myCase.

* 3200 online chats per week mean less time for clients waiting on hold to speak to an eligibility specialist about their case.

While we realize that there will always be a portion of clients who are either unable or uncomfortable managing their case electronically, creating more avenues for people to keep their kids' health coverage is always a good thing. Administrative simplification seems to be a win for everyone; the state saves money and more kids stay enrolled. Voices for Utah Children will continue to pursue additional administrative simplification measures to benefit our kids.

Maybe it's the famine in Somalia, the ever-fluctuating stock market, the riots in London, the ongoing deficit and debt talks, but I'm in some serious need of good news. Thanks to Jenny Kenney and her colleagues at the Urban Institute, we've got some - participation in Medicaid and CHIP has gone up!

Their new report finds that the number of children eligible for Medicaid/CHIP increased by about 2.5 million between 2008 and 2009. On a national level, about half of this increase was due to the recession and the decline in income; the other half is the result of eligibility expansions (as with most things Medicaid, this division varies by state).

But despite the increase in the number of eligible children, participation also rose from 82.1% to 84.8%, and was higher (84.9%) among those who were previously eligible, than those who were newly eligible due to an expansion in eligibility (76.5%). There's that welcome mat effect!

Participation increased across the country, with the greatest increases in the South and in the West. Thirty states saw significant increases in their participation rates - with Colorado topping the list at an 11.4 percentage point increase. The increases occurred for children of different races/ethnicities, ages, incomes, and languages; only non-citizen children didn't experience a significant increase in participation.

The effect of all this? A reduction in the number of eligible, but uninsured children by about 340,000. This decline in uninsurance among the eligible kids contributed to the overall decline in the uninsured rate for ALL kids seen during this time period.

But alas, our work is not done. There are still an estimated 4.3 million eligible, but uninsured children out there. Almost 40% of them are in just three large states - Texas, California, and Florida - and 62% live in one of 10 states.

While it will not be easy to get all the remaining eligible kids covered, there are plenty of states to look to as role models. In fact, 16 states now have participation rates at or above 90%. If every state reached this level of participation, just 2.8 million eligible, but uninsured kids would remain; if every state obtained a 95% participation rate, the number would be only 1.4 million. Don't know about you, but I'm feeling a little better now.

Even if you tend to gloss over my technology blogs, please keep reading because this is really BIG news for the states. Yesterday, CMS announced that, for a limited time, it is waiving the requirement that the cost to replace or improve integrated eligibility systems be allocated across programs (at each program's matching rate). Let's dive into what this means for states.

Earlier this year, CMS announced the availability of enhanced federal funding for new or upgraded Medicaid eligibility systems with the federal government picking up 90% of the development cost (referred to as the 90/10 rule). The biggest drawback with this generous offer is that 44 states have integrated systems that manage eligibility for other programs like SNAP and TANF, in addition to Medicaid and CHIP. Those states face the dilemma of choosing between 1) delinking and building a new separate Medicaid eligibility system or 2) coming up with the higher state match for the proportional cost of the system represented by the other programs.

The issue for the states involves more than just money, which is not insignificant given the current fiscal environment. The prospect of operating separate systems on an ongoing basis requires rethinking how human service agencies and counties manage their eligibility work. But more importantly, it presents additional barriers to families who benefit from other programs. States and advocates alike have been concerned that delinking would mean that coordination of benefits across programs would become more complicated which is contradictory to the goals of the ACA to move toward a simplified, more coordinated system among the various health coverage options.

The latest announcement, jointly issued by the US Department of Agriculture which administers SNAP and three agencies within the Department of Health & Human Services, allows that development costs that would be incurred for the Medicaid, CHIP or Exchange portion of the system (like an on-line application) do NOT have to be cost-allocated regardless of whether other programs benefit. Only incremental costs for additional requirements to integrate the non-health programs must be charged to the specific program. Ongoing operational costs will be cost-allocated under the traditional rules. The cost-allocation between Exchange (100% federal) and Medicaid (90% federal) functionality remains in place. All systems also must meet new federal standards to ensure accessibility, functionality and performance.

The tight timeline for getting the new Medicaid, CHIP and Exchange eligibility system up and running may mean that states still may have to phase-in integration of the other public assistance programs. The temporary waiver from cost-allocation rules, which is effective immediately, will remain in effect until December 31, 2015. This gives states about 2.5 years to re-integrate other human service programs after they need to have the Medicaid/Exchange eligibility system functional. This timeline coincides with the expiration of the 90/10% enhanced federal match for Medicaid systems when system development costs revert back to a 50/50 match.

For states that are looking at major new system development, it seems logical to think about several phases in building these systems. Phase 1 implements eligibility for all coverage options that will rely on Modified Adjusted Gross Income (MAGI). Phase 2 would bring in the other Medicaid groups that will continue to rely on traditional eligibility methodology. And Phase 3 would re-integrate the human service programs such as SNAP, TANF and child-care subsidies. The current systems would continue to handle eligibility for the non-MAGI groups and human service programs in the interim. However, states that have already moved to more sophisticated technology may be able to move forward more quickly.

Overall, the temporary waiver of cost-allocation rules is icing on the 90/10 cake! This is an even sweeter deal for states to replace those clunker legacy systems and use state-of the-art technology to provide consumer-friendly, efficient and cost-effective access to health coverage and other key family supports. For more information on the temporary cost-allocation waiver, click here.

(Editor's Note: In an effort to keep our readers up to speed on what's happening on the development of state-based health insurance exchanges, we are checking in periodically with states that are moving forward.  This month, we visit our friends in sunny California.)

By Nicette Short (Children Now) and Kathleen Hamilton (The Children's Partnership) on behalf of the 100% Campaign

Earlier this month,  California's Health Benefit Exchange Board (the HBEX) met for the first time with a full complement of Board members (Dr. Robert Ross, CEO of The California Endowment was recently appointed to fill the fifth and final seat on the Board) . The Board approved a $40.1 million Level I Establishment Grant application and vowed to send it off to HHS within 48 hours.

Considering that the Board only held its first meeting in April, and originally decided to submit a Level II Grant application in September, completion of this earlier submission was an impressive feat.

So, the planning begins...The Board's Acting Administrator Patricia Powers detailed the immediate next steps.  The Board will undertake a "strategic visioning" process, and next week will announce strategic work groups.. The inaugural working group will focus on eligibility and enrollment requirements, issues and challenges. Noting that well over half of the planning grant ($27.8 million) will be devoted to IT, the Board Chair, Secretary Diana Dooley reminded meeting attendees that while IT is "short hand for enrollment," enrollment will not be limited to online access. Providing for telephone, mail-in, and in-person access and assistance will also be key components of the Exchange's enrollment and eligibility planning.

Powers announced that the grant application had been revised somewhat to address advocate concerns that some planning areas had not been sufficiently funded. Funding to plan for stakeholder consultation, program integration and consumer assistance and outreach were all increased in the final proposal. The allocation for health plan management was also increased, at the request of Board member Susan Kennedy.

The need for the Board to "cement public awareness" was articulated by Betsy Imholtz of Consumers Union. Powers reported that a portion of an earlier federal grant to California's Department of Managed Health Care would be used to redesign the HBEX website as a critical first step to HBEX branding.  A recurring drumbeat has been the need create a "brand" for HBEX that invites consumer participation and engages the public. Since approximately one-third of Exchange enrollees are expected to be families with no history of engagement in public health programs, it is clear that new avenues for reaching Californians must be developed.

HBEX must find ways to not only let people know they're here...but that access to healthcare is for everyone.

Next month we'll report on the stakeholder and working group developments!

In this week's release of the Exchange/Medicaid IT 2.0 guidance, the Centers for Medicaid and Medicare Services (CMS) firmly squashed speculation that states will need to operate a "shadow eligibility system" for determining who is newly eligible for Medicaid and therefore qualifies for 100% federal funding. Future federal rulemaking is expected to propose other methods for managing accounting of the appropriate federal match.

The guidance provides new details on CMS's intent to develop a federal data services hub that will serve as a reliable, centralized data source for all states to access critical information to verify citizenship, immigration and modified adjusted gross income (MAGI) on which eligibility for financial assistance is based. CMS is exploring additional functions to be incorporated in the data hub, such as the potential to identify employer, federal or other Exchange coverage and information needed to administer premium tax credits and cost-sharing subsidies.

This second iteration of guidance for Exchange Information Technology (IT) systems continues to emphasize the importance of delivering a "high quality customer experience, as well as seamless coordination between Exchanges, Medicaid and CHIP and between the Exchanges and health plans, navigators, brokers, community-based organizations and providers." The guidance also applies to Medicaid Eligibility and Enrollment Systems funded through the enhanced 90/10 federal funding rule that became final earlier this year.

In version 2.0, CMS reiterates that customers should encounter a high level of service, support and ease of use, similar to that provided by online retailers such as Amazon or Travelocity. The expectation is that all individuals seeking coverage, regardless of the coverage source or level of financial assistance, will receive the same customer experience. The intent is to make it easy for individuals to explore information about health coverage options and be evaluated for eligibility for tax credits in the Exchange, or for Medicaid or CHIP, in real time. The guidance actually suggests that most individuals should be able to complete the application and get an eligibility decision quickly (for example, 15 to 20 minutes), before moving on to an equally expedited process to choose and enroll in a health plan.

CMS acknowledges that while a large number of consumers will be served directly through the online system, some individuals will prefer to apply by phone, by mail or in person (no wrong door). While individuals seeking coverage will be able to access information and assistance through multiple doors, all doors will connect to a standardized web-based system to evaluate the individual's eligibility for all coverage options: the Exchange, Medicaid, CHIP or the Basic Health Plan (if applicable).

In order to accommodate these objectives, CMS expects the use of a common or shared eligibility system or service to determine eligibility for most individuals within a state. Integration of systems, programs and administration will limit duplication of costs, processes, data and effort on the part of both states and consumers. While the guidance continues to emphasize the importance of developing and sharing IT resources among states, CMS affirmed that it does not intend to impose a single IT solution on individual states. The agency will promote and foster the development of flexible systems that produce the intended business results, meet specific standards and produce data and reports in support of performance management, public transparency, policy analysis and program evaluation.

If you're searching for the more technical stuff, you can find the guidance here. It also includes a list of Exchange Architecture Guidance (EAG) documents, which serve as the master systems architecture plan. These documents have been provided in draft form to Exchange grantees and will be posted on the CMS website when finalized.

This week, the Department of Health and Human Services (HHS) awarded the first round of grants to help states establish health insurance exchanges.  State officials in Washington, Indiana and Rhode Island were granted a total of $35 million to begin building their exchanges. In announcing the grants HHS said that the states "will use the money to build up the necessary information technology systems -- a major undertaking for which even conservative governors have sought federal help."

An HHS fact sheet summarizes the grant activities as follows:

* Indiana received almost $7 million "to strengthen the health information technology systems that will be integral to its Exchange. Additional funding will support project management, legal, actuarial, and financial expertise and general policy support."

* Rhode gets $5.2 million "to strengthen health information technology systems, develop an integrated consumer support program to provide support to individuals and small businesses, and strengthen its business operations."

* Washington will receive nearly $23 million "to develop options and recommendations on policy decisions that will have a significant impact on the Exchange. The grant will also provide funds to develop a health information technology system that will support its Exchange."

The establishment grants follow a round of planning grants where each state (except Alaska, which didn't apply) received a $1 million to get started on the exchange planning process, and the awarding of a total of $241 million to six "innovator" states and one New England-based multi-state consortium to develop exchange information technology (IT) infrastructures that other states can adopt and adapt.

Each of the new exchange establishment grants was for level 1 funding, which means the state sought funding for an initial year of work. Alternatively states may apply for level 2 and incorporate all of their funding needs for the establishment and operation of the exchange(s) through 2014. HHS designed the establishment grant opportunity with maximum flexibility for states. States can apply for funds on a rolling basis, and can either seek multi-year funding (level 2) or take a step-by-step approach by applying for annual project grants (level 1). Award amounts, sufficient to fulfill the purposes of the funding opportunity, will vary based on the proposed activities and specific needs of each state. Funds can be used for a number of different activities, including consulting with stakeholders, making legislative and regulatory changes, governing the exchange, establishing information technology (IT) systems, performing oversight and ensuring program integrity.

In order to securing ongoing funding, each state must make progress toward establishing an Exchange, implementing market reforms and meeting other benchmarks as the Secretary may establish. Benchmarks must be identified in each of these core areas: background research; stakeholder involvement; legislative/regulatory action; governance; Exchange IT systems; program integration; financial management; oversight and program integrity; health insurance market reforms; providing assistance to individuals and small businesses, coverage appeals and complaints; and business operations/exchange functions.

Examples of critical benchmarks include evidence of collaboration between exchanges and state Medicaid agencies or submission of data collected by the state Consumer Assistance programs regarding problems consumers encounter and actions taken by the state to resolve them.

The next funding cycle will close on June 30, 2011. Quarterly opportunities will continue for a total of five more quarters until June 29, 2012. Decisions on grant applications will be made approximately 45 days after each application due date.

By David Blatt, Director of Oklahoma Policy Institute

In the new national health care law (the Affordable Care Act, or ACA), exchanges are state-level competitive marketplaces for individuals and small businesses to purchase insurance. After winning a $54 million Early Innovator grant earlier this year, Oklahoma was poised to become a national leader with a high-quality, consumer-oriented health insurance exchange. In a state that ranks 46th in overall citizen health and where almost one in six residents are without health insurance, the decisions our leaders make regarding the exchange are critical to our efforts to expand coverage and improve our state's health care infrastructure.

Governor Mary Fallin and legislative leaders' recent decision to reverse course by rejecting the federal grant and relying instead on state and private money to build an "Oklahoma Health Insurance Private Enterprise Network" is a symbolic victory for the most vocal opponents of health reform.  Unfortunately, this puts unnecessary strains on the state budget and sends Oklahoma on a collision course with federal law. More importantly, it is likely to deprive Oklahomans of access to a strong, well-regulated, consumer-friendly marketplace to purchase private insurance coverage and will do nothing to actually make health insurance more affordable for Oklahomans.

One of the most important provisions of the Affordable Care Act is the requirement that states establish private insurance marketplaces, or 'exchanges', to sell plans to individuals and small groups in their state beginning January 1, 2014. States have some flexibility in setting up their exchanges, but all exchanges must meet certain minimum requirements set out in Section 131 of the ACA. In particular, the online exchanges must:

• Certify that plans sold in the exchange meet quality standards. Qualified health plans must offer essential benefits and meet regulatory standards for provider networks, quality improvement, accreditation and more.
• Review rate and premium increases. Exchanges will review and approve premium increases and mandate that insurance companies spend most consumer premium dollars directly on medical care, not overhead or administration.
• Enroll individuals and businesses in a user-friendly way. The exchange must allow consumers to view, compare, and purchase coverage online.  Exchanges must also determine an applicant's eligibility for tax credits that subsidize the cost of coverage, as well as determine eligibility and enroll individuals in Medicaid and other public programs.
• Provide consumer-friendly features like a toll-free hotline, an online cost-of-coverage calculator, access to "navigators" to assist with enrollment, and more.

In other words, the exchange envisioned by the Affordable Care Act is not just a website that enables plan and premium comparisons - consumers can do that now through existing websites and search engines. It is a full-fledged health insurance marketplace where private insurance will be sold and regulated with robust consumer protections.

Oklahoma is well-positioned to implement this kind of strong exchange. For example, the Insure Oklahoma program is a partnership that provides public subsidies to small businesses and their employees for the purchase of private insurance. The Oklahoma Health Care Authority already operates an online system to determine eligibility and enroll applicants in Medicaid and other health benefit programs. The state also operates the Oklahoma Health Information Exchange to expand the use of health information technology to  promote better health care. This existing infrastructure is what led Oklahoma to receive the Early Innovator Grant, which in turn provided the opportunity for Oklahoma to construct an integrated, technologically-sophisticated exchange.

Is there any chance that Oklahoma will develop a strong exchange after rejecting the federal grant? The answer is almost certainly "no," for both fiscal and political reasons. Without federal dollars, Oklahoma lacks the resources to build a strong, effective exchange. Speaking to a meeting of health insurance underwriters in March in defense of her decision to accept the $54 million, Governor Fallin was asked about the feasibility of rejecting the federal grant and generating state money for an exchange. After noting that all state agencies have taken cuts over the past two years and that the state faces a $500 million budget shortfall for the year ahead, the Governor replied:

"So things have been pretty tight. I'm all about tightening our belts and creating more efficiency and effectiveness but there are some of our state programs that are kind of getting to the bare bones. So do we have the state money for the exchange? No we don't."

This is what led the Oklahoman to conclude that in rejecting the federal grant, "ideology trumped common sense."

Yet even if the money to support an exchange were to materialize, the state's political leaders have signaled their intent to resist developing an exchange that conforms to the requirements of the Affordable Care Act.  Last week, legislation to implement the 'Oklahoma Health Insurance Private Enterprise Network',  SB 971, was introduced in the Senate. Apparently responding to pressure from insurance companies, agents and underwriters, the state's "non-exchange" would be little more than a search engine for information and referrals.

The network set out in SB 971 falls well short of meeting even the most basic standards set out in the Affordable Care Act in several respects.  The network would be expressly precluded from exercising regulatory authority, even though federal guidance has specified "regulatory standards in five areas that insurers must meet in order to be certified as qualified health plans by an Exchange." SB 971 seems to require the network to accept all health plans, even those that fail to meet the essential health benefits package or quality standards that the ACA deems necessary in order to participate in the exchange. The network seems unlikely to be able to assume core exchange functions, such as determining applicants' eligibility for subsidies or public health insurance coverage, directly enrolling individuals and small businesses in coverage, or coordinating eligibility and enrollment between multiple programs. It also creates a governing entity which excludes the Medicaid agency and in which two of the seven seats are reserved for the insurance industry but only one for a consumer: it's not hard to predict whose interests would be best represented.

These deficiencies raise the specter of the federal government stepping in to create a real health insurance exchange in Oklahoma - precisely the threat that spurred Gov. Fallin to accept the $54 million federal grant in the first place. It is still possible that the network could eventually meet federal standards. But for now, it looks as if Oklahoma is more intent on proving its defiance of Washington and responding to interests and fears of the insurance industry than it is in creating an insurance marketplace that would actually benefit everyday Oklahomans.

Remember driving an older model car that generally got you from point A to point B but not without stalling at a traffic light or having the heater cut out in the dead of winter? That's a bit like the old, tired legacy systems currently being used to determine eligibility for Medicaid (and other programs) in many states today. The good news is that states now have a strong financial incentive to replace or upgrade those systems to bring them in line with 21st century technology.

Yesterday, CMS issued a final rule that will provide 90 percent of the cost for states to develop and upgrade their IT systems to help people enroll in Medicaid or the Children's Health Insurance Program (CHIP), and 75 percent of ongoing operational costs. The rules also establish performance standards for the improved eligibility systems to promote greater efficiency and a more consumer-friendly enrollment process.

There is a lot of techie detail in the rule, as well as CMS's responses to comments, regarding the requirements that these systems must meet in order for system design, development and implementation costs to be qualify for 90 percent federal financial participation. I'm not sure that readers of Say Ahhh! want to dig into that kind of nitty gritty on a Friday afternoon, so I'll try to stick to the highlights. 

The rule emphasizes the need for a modular, flexible approach to systems development that promotes both the ease of maintenance as well as the sharing, leverage and reuse of systems within and among states. What╒s really important to most of us is that these systems are expected to improve enrollment and renewal by:

• Supporting accurate and timely processing of eligibility decisions and effective communications with providers, beneficiaries and the public,
• Producing transaction data, reports and performance information that contribute to program evaluation, continuous business improvement, and transparency and accountability
• Ensuring seamless coordination with the Exchange and allow interoperability with health information exchanges, public health agencies, human services programs and community organizations providing outreach enrollment assistance services.

It's important to keep in mind that this is a time-limited opportunity. To qualify for the 90 percent funding, states must incur costs for goods and services furnished no later than December 31, 2015. But to help states get started right away, the rule waives both the 30- and 60-day delay in effective date.

In the coming weeks and months, we'll continue to dig into the technology-related issues to help advocates understand the opportunities for them to have input into system development as states move forward. While it may not be as easy as shopping for a new car, driving it off the lot will be every bit as exciting as we see the emergence of enrollment and renewal systems that deliver on the promise of a 21st century, customer-focused experience.