By Martha Heberlein and Tricia Brooks

Of late, most of the media attention on ACA implementation has focused on the technical glitches in the federal (and to a lesser extent state) marketplaces and the end of inadequate individual insurance plans, while state Medicaid agencies have been hard at work behind the scenes revamping their business processes and creating more consumer-friendly eligibility and enrollment systems. Medicaid’s early successes in connecting folks to coverage seems to have caught many people by surprise but indeed, Medicaid is a workhorse under the ACA. In fact, Medicaid is expected to serve more than half of those gaining coverage in 2014 – almost 5 million low-income adults – despite the fact that not all states have accepted the generous federal funding to expand the program.

While the 26 states, including DC, are gearing up to expand coverage on January 1, 2014, all states are in the process of transforming their eligibility processes. At the same time states are modernizing the application experience; they must also align the requirements for Medicaid, CHIP, and premiums tax credits in the Marketplaces to facilitate a coordinated enrollment system. Over the past year, states have made steady and significant progress preparing for these changes; however, as our interim report with the Kaiser Commission on Medicaid and the Uninsured shows, readiness varies considerably as 2014 nears.

A few highlights from the report –

• Eligibility levels for parents and other adults will significantly increase in states implementing the Medicaid expansion, while nearly 5 million uninsured adults will have no new option for coverage in states not adopting the expansion. In the expansion states, the median coverage level for adults without dependent children will rise from 0% to 138% percent of the FPL level while remaining at zero percent in non-expansion states. Additionally, coverage for children and pregnant women remains strong. 

• Eligibility levels have been converted to account for income disregards and deductions that will no longer apply under the new modified adjusted gross income (MAGI) rules, plus a new standard disregard equal to five (5) percentage points of the federal poverty level.

• The ACA envisions seamless and timely access to the continuum of health coverage options regardless of where or how someone applies and as of October 1, 2013, 43 of 50 reporting states have deployed a single, streamlined application, with the rest working to do so by the January 1^st deadline. However, coordination between state Medicaid/CHIP agencies and the federal Marketplace has been hampered by technical problems that are delaying transfers between the programs.

• Beginning in January 2014, states are expected to rely on trusted electronic data rather than paper documentation to verify eligibility. They are submitting verification plans that outline the data sources and procedures they will use and, from the plans available, it appears that states are embracing the shift to a paperless approach to verification.

• Faced with the task of processing applications for large numbers of people who become newly eligible for Medicaid on January 1^st, CMS has offered states five tactics to help manage the transition. Thirty (30) states have adopted at least one of these strategies and early data show the great success states have had in capitalizing on these approaches to help individuals and families secure coverage.

January 1^st represents just the first step toward a modernized, streamlined system to connect individuals to expanded coverage options as established through the ACA. Fully achieving that vision will require time, persistence, and a commitment to continual program improvement. And for those of you itching for more details as implementation moves forward, rest assured – we will be conducting the full 50-state survey on eligibility, enrollment, renewal and cost-sharing after the dust settles in the spring.