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