My colleagues just released a helpful update on state progress in creating more consumer-friendly eligibility and enrollment systems.  If you’re like me, when reading Medicaid eligibility terms like “MAGI conversion” and “flat file,” your mind wanders to a foreign money exchange or even a children’s book character—yes, the omnipresent Flat Stanley—rather than focusing on people enrolling in health coverage.  I thought a little decoding of eligibility and enrollment lingo might come in handy.  You might also want to check out a piece that CQ’s Rebecca Adams wrote last week that translates health tech lingo.

• Single streamlined application – These are applications that screen for all health coverage options (Medicaid, CHIP and advance premium tax credits). State Medicaid agencies have to make one of these available through multiple modes: online, by phone, and on paper by January 1, 2014.   States can either adopt the federal model application or use a state application that is approved by HHS.  For more on this, you can check out Martha Heberlein’s blog post.

• Verification plan – The ACA is the catalyst for a major change from paper-based manual eligibility determinations to automated online determinations made using electronically available information.  State verification plans provide detailed information about how a state will verify the accuracy of information when information provided by an applicant differs from information provided from electronic databases.  They also include useful details about what data sources the state will use, and the frequency of checks. You can read Tricia Brook’s blog post on verification plans for more info.

• Reasonable compatibility – The ACA calls for reasonable compatibility standards to address situations where an applicant’s self-attested information and electronic sources of information are inconsistent.  In cases where self-attested income is above the standard and electronic data are below, or vice versa, the ACA gives states the flexibility to define when inconsistencies between the two sources are considered “reasonably compatible,” and the self-attestation can be used.   For those of you into statistics, I think of this as being like the margin of error.  If the margin of error is greater than a certain defined amount, like $50, then the self-attested income and electronic data are not reasonably compatible.  In that case, states can accept a reasonable explanation of the difference or request paper documentation of the income to validate the current income.

• Eligibility Assessment v. Eligibility Determination – The difference here is not in how the federally facilitated marketplace (FFM) determines eligibility for Medicaid or CHIP, but rather what the state Medicaid agency does with the information that the FFM provides. In both an assessment and determination model, the FFM will use the same set of eligibility criteria, including selected state-specific options, and the FFM will transfer an electronic file to the state. In an “eligibility determination” state, the state will accept the FFM’s determination of eligibility as final and will enroll those who are eligible.  In “eligibility assessment” state, the state will receive the file transfer from the FFM and complete the eligibility review using its own rules.  See Tricia Brook’s blog post for more info.

• Flat file – The flat file is a set of basic data on applicants assessed or determined eligible for Medicaid and CHIP that CMS is sharing with states.  Because of delays in transferring Medicaid/CHIP applicants directly from the FFM to states, CMS is giving states the option of applying for a time-limited waiver to enroll applicants based on the data in these flat files. This is a relatively new term of use in this context, for more info on this, read Martha Heberlein’s recent blog post.

• MAGI – Under the ACA, eligibility for income-based Medicaid and subsidized health insurance through the Marketplaces will be calculated using a household’s Modified Adjusted Gross Income (MAGI), a standard borrowed from the Internal Revenue Code.  This is in an effort to simplify complex income counting rules that varied across the states and eligibility category.  However, the calculation of MAGI is slightly different for subsidized health insurance than it is for Medicaid. The MAGI definition for Medicaid excludes a few additional items from income, such as scholarships for education purposes.

• MAGI conversion – To transition to MAGI-based eligibility, states have to convert their current income eligibility rules to a new simplified MAGI income level.  The MAGI threshold is intended to approximate their existing income eligibility levels in the aggregate to prevent individuals and families from losing coverage as the state transitions from existing eligibility rules to MAGI.  They are intended to result in roughly the same number of people being eligible as would have been eligible under the new standard

• 12 month continuous eligibility – This federal policy option for children pre-dates the ACA, and allows states to provide Medicaid and CHIP eligibility for children for 12 months straight, regardless of certain changes in family circumstances, like fluctuations of income.  In the absence of continuous eligibility, Medicaid or CHIP eligibility may change when enrollees report changes in family circumstances, like fluctuations in income.  Under the ACA, CMS has offered states the opportunity to allow 12-month continuous eligibility for parents and other adults. So far, no state has yet adopted the option.