Out of the Shadows: Exchange/Medicaid IT 2.0 Guidance Says No Need for Duplicate Eligibility Systems – Say Ahhh! A Children’s Health Policy Blog

In this week’s release of the Exchange/Medicaid IT 2.0
, 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.

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