CMS Proposes A Medicaid Rule You (and States) Might Like – Say Ahhh! A Children’s Health Policy Blog

I’m not big on rules. When I ran New Hampshire’s
Children’s Health Insurance Program 
and had to talk with a family who was unhappy about some bureaucratic
rule, I often diffused the conversation by saying “I don’t make the rules, if I
did there wouldn’t be any.” I know, that was a cop-out but it worked. Now I
take those words back. This is one rule I might love!

The Centers for Medicaid & Medicare Services (CMS) has
published a proposed rule in the federal register that would broaden the
definition of “claims” to include “claims of eligibility” in regard to Medicaid
management information systems. What does this really mean? It means that
eligibility systems may qualify (assuming the rule is adopted) for a 90%
federal financial participation to support the design, development, testing and
implementation of new or enhanced eligibility systems capacity through 2015.
Systems could also qualify for an ongoing 75% federal match once they are

Is this a big deal? Indeed it is. States have been
severely encumbered by a lack of resources to make system innovations or
replace decades old legacy systems that, quite frankly, have outlived their
usefulness due to a lack of major overhauls. Moving forward on streamlining
efficiencies and the use of data matching to verify eligibility helps both
states and real people but requires the latest in systems architecture and
performance to achieve the innovations that we know are possible. These kinds
of system transformations, along with seamless integration with Exchange IT
systems, require major investments and the enhanced federal funding
will be welcome news to cash-strapped states.

So, we commend CMS leadership for rightly justifying this
rule change to ensure that Medicaid eligibility systems are as efficient and
effective as possible and ready to fulfill the promise of coverage for millions
of low- and moderate-income people envisioned by the Affordable Care Act. It is
worth emphasizing that this is a time-limited opportunity (through 2015) and,
given the time required to build these systems, states should get to work

The proposed rule was accompanied by new guidance for
Exchange and Medicaid Information (IT) Systems that establishes a framework and
approach for Exchange IT systems developed through the new Innovator Grants and
for Medicaid IT systems supported by the 90% funding proposed in the
rulemaking.  The Office of Consumer
Information and Insurance Oversight (OCIIO) teamed up with CMS
to issue the
guidance.  It  will be updated over time, requiring
states to comply with future iterations as well.

Coupled with last week’s announcement of 100% funding for
five model Exchange IT systems through the Innovator Grants, this is big news
and cause for celebration. There’s more detail worth sharing on the Innovators
Grants that I promised when I posted the announcement. But first I have to
update that blog because this latest action addresses a couple of issues I felt
were omitted in the Innovator Grant release.

Without getting into the really technical requirements
(which I’m not qualified to do), here are a few provisions that warm my heart:

1) The guidance requires IT systems to support a
first-class customer experience, as well as seamless coordination between the
Medicaid and CHIP programs and the Exchanges and between Exchanges and plans,
employers and navigators.

2) The guidance also confirms that systems must comply
with new 1561 standards developed by the National Office of the Coordinator for
Health Information Technology, which envision consumer-focused systems that
interface across multiple assistance programs. (Look for more on this in the
Innovator Grants Part II blog.)

3) In the proposed rule, CMS anticipates additional
standard federal requirements for more timely and detailed reporting of eligibility and enrollment statistics. The proposed rule goes on to indicate
that CMS will develop a range of data and performance metrics on which states
would be required to report on an ongoing basis. (This is where “like” turned
to “love” for me!)

4) Like the Innovator Grants, states will be encouraged
to share and reuse Medicaid technologies and systems within and among states.

5) Interoperability goes further than interfacing with
Exchange IT systems and includes public health agencies, human service
programs, and my favorite – community organizations providing outreach and
enrollment assistance services.

All in all, the Innovator Grants, the proposed 90%
funding for Medicaid IT systems, federal IT guidance with more to come,
technical assistance from CMS and ICIIO and incentives for states to share and
learn from one another will go a long way to bring the use of technology into
the 21st century for our public coverage programs. There’s a lot of work to be
done but no longer are we waiting for guidance and the extra resources to get
started. Up first on our list is to make sure the proposal becomes the final
rule. CCF will be working with our partners to draft supportive comments and to
ensure the final rule is as strong for beneficiaries as possible. So stay

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