Eligibility and Enrollment Processes for Medicaid, CHIP, and Subsidies in the Exchanges

After the Patient Protection and Affordable Care Act (PPACA) became law, a state-based system of health benefit exchanges was established. This system will allow individuals to purchase coverage, with financial support for those between 133-400 percent of the federal poverty level, and expanding Medicaid eligibility to those with income below that level.

A number of provisions in the PPACA require states to design and operate coordinated, technology-supported enrollment processes to assist Americans who lack access to affordable employer-based coverage in obtaining health coverage through Medicaid, the Children's Health Insurance Program (CHIP), or the state exchanges. The law requires states to develop consumer-friendly application processes for these health subsidy programs, coordinate across them to enable seamless transitions, and reduce the burdens of application and renewal by minimizing the up-front information and documentation required to establish eligibility and instead developing procedures that tap available data from other sources.

The charts below summarize and provide highlights of the legislative language from PPACA regarding the main enrollment provisions, particularly those of relevance to low -- and moderate-income families. These provisions require enrollment systems that are:

  • Consumer-friendly: PPACA requires states to create enrollment systems that ensure that applicants are screened for all available health subsidy programs and enrolled in the appropriate program, with minimal collection of information and documentation from applicants.
  • Coordinated: PPACA requires states to coordinate efforts across available health subsidy programs to enable seamless transitions between those programs.
  • Simplified: PPACA requires states to operate a streamlined enrollment process and foster administrative simplification, using uniform income rules and forms as well as paperless verification procedures.
  • Technology-enabled: PPACA requires states to operate enrollment Web portals and securely exchange and utilize data to support the eligibility determination. In addition, PPACA directs the Secretary of Health and Human Services to establish standards and protocols for electronic enrollment and eligibility systems, to allow for significantly improved streamlining and cross-agency capabilities.

With the passage of health reform, the United States has begun to build a culture of coverage, laying the foundation for this culture shift through new health coverage options, protections, and subsidies, as well as through provisions that promote individual responsibility.

The first stone in this foundation has been laid with the July 1, 2010 launch of a federal informational Internet portal, healthcare.gov, which will ultimately have significant operational capabilities. Further, PPACA tasks states with constructing an enrollment system that assists people in understanding their choices and helps them obtain and keep appropriate health coverage. In order to achieve the optimal enrollment process, with the technology that can support it, states need to begin planning and developing their policies, procedures, and systems right away, to ensure deployment by 2014.

CONSUMER-FRIENDLY
Summary Section Specifics
Helps consumers understand their options ? 1103 The Secretary of Health and Human Services (Secretary) will create, operate, and update an Internet portal to help consumers identify and compare available affordable coverage options, including Medicaid and CHIP. The portal was launched July 1, 2010.
? 1311(c)(5) The Secretary will also design, for use by the exchanges, a model template for an Internet portal that will assist individuals in "determining whether they are eligible to participate in an Exchange or eligible for a premium tax credit or cost-sharing reduction," among other functions.
Helps families apply online ? 2201
[New ?1943(b)(1) of the Social Security Act (SSA)]
States are required to operate an Internet website that links the exchange, Medicaid, and CHIP (as relevant). These websites shall allow individuals to compare available health subsidy programs and apply for or renew such coverage. State websites must be in operation by January 1, 2014.
Provides for a single, streamlined application form ? 1413 The Secretary is required to develop a single, streamlined form that states can use for all those applying on the basis of income to applicable state health subsidy programs and that can be filed by an applicant online, in person, by mail, or phone. States can develop their own single, streamlined form as an alternative to the Secretary's form as long as it meets the same standards.
For applicants not applying on the basis of income, such as foster children and SSI beneficiaries, states may use a supplemental or alternative form.
Reduces administrative burdens on applicants ? 1413(b)(2) Individuals filing the single form "shall receive notice of eligibility for an applicable State health subsidy program without any need to provide additional information or paperwork unless... information provided on the form is inconsistent with data used for the electronic verification... or is otherwise insufficient to determine eligibility."
? 2002(a) No asset test will be applied in Medicaid for individuals whose income is calculated using modified adjusted gross income (MAGI), including parents and other non-elderly adults as well as children.
Expands presumptive eligibility for Medicaid applicants ? 2202 At state option, all hospitals participating in a state Medicaid program can grant presumptive eligibility to all Medicaid eligible populations (not only pregnant women and children). This option is effective January 1, 2014.
Provides assistance to help consumers obtain coverage ? 1311(i) Exchanges will set up a Navigator grant program to provide fair and impartial, culturally and linguistically appropriate information concerning enrollment in qualified health plans and available subsidies through the exchange, facilitate enrollment in qualified health plans, and provide referrals for complaints.
? 2201[New SSA ?1943(b)(1)(F)] In addition, states will establish procedures for conducting outreach and providing enrollment assistance to vulnerable and underserved populations eligible for Medicaid and CHIP.


COORDINATED
Summary Section Specifics
Requires coordination between exchanges, Medicaid, and CHIP ? 2201
[New SSA ? 1943 (a) and (b)]

Requires, as a condition of federal financial assistance (i.e., federal Medicaid matching funds) beginning January 1, 2014, that states establish streamlined application and renewal procedures that:

  • Enable individuals to apply for, be enrolled in, or renew Medicaid coverage through an Internet website that is linked to the Exchange website;
  • "Enroll... without any further determination by the State and through such website, individuals who are identified by an exchange... as being eligible for" Medicaid or CHIP;
  • Ensure that individuals found ineligible for Medicaid or CHIP are screened for the exchange and any applicable premium assistance and, if eligible, "enrolled in such a plan without having to submit an additional or separate application" and receive information regarding reduced cost-sharing and any other assistance or subsidies that are available through the exchange.
? 1311(a) and (d)(4)(F) The Secretary will award states exchange "planning and establishment" grants by March 23, 2011, which may be renewed until January 1, 2015. Planning and establishment must ensure that the exchange has the ability, among other specified functions, to inform individuals about Medicaid, CHIP, "or any applicable State or local public program," screen their application, and enroll individuals in any of those programs as appropriate.
Medicaid and CHIP agencies may determine eligibility for premium tax credits ? 2201
[New SSA
? 1943(b)(2)]
A Medicaid or CHIP agency can enter an agreement with an exchange to determine eligibility for premium assistance if the agreement "meets such conditions and requirements as the Secretary of the Treasury may prescribe to reduce administrative costs and the likelihood of eligibility errors and disruptions in coverage."

Source: Kaiser Family Foundation

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