People who are eligible for Medicaid or CHIP in their state do not qualify for premium tax credits (or cost-sharing reductions) to help pay for a qualified health plan (QHP) in either a state-based exchange or the federally-facilitated marketplace (FFM). When someone applies for coverage through the FFM in the 34 states that are not building their own marketplace, the FFM must first assess the individual’s eligibility for Medicaid or CHIP. Medicaid and CHIP agencies, independent of each other’s decision, have the option to accept the FFM’s assessment as a final eligibility determination. So what’s the difference between an assessment and a determination? A recent FAQ released by CMS provides additional information about this key element of coordination between the FFM and state agencies.
In both an assessment and determination model, the FFM will use the same set of eligibility criteria, including selected state-specific options (such as whether a state covers lawfully-residing children and pregnant women) and standard verification procedures, which rely on electronic data sources available to the FFM. In both models, an electronic “file” that includes all the individual’s information collected during the application or renewal process by the FFM will be transferred to the state Medicaid or CHIP agency. Receipt of this data is expected to trigger an acknowledgement to the FFM that confirms the transfer was successful. This transfer of data works both ways; that is, the reverse happens if someone applies through the Medicaid agency and is assessed as eligible for coverage in the FFM.
In a determination model, the state will accept the FFM’s verification of MAGI-based eligibility (i.e. children, pregnant women, parents, and the newly eligible adult group) as a final determination. Individuals determined eligible by the FFM will be enrolled by the state Medicaid or CHIP agency once the state receives the electronic account transfer from the FFM. The FFM will not determine eligibility for non-MAGI Medicaid (although screening questions will be asked on the single, streamlined application). For state-based exchanges that are government entities, states may choose to have the exchange make both MAGI- and non-MAGI Medicaid decisions.
If a state does not accept a final eligibility determination (assessment model), it will receive the electronic file transfer and complete the eligibility review according to its own rules. The state may require additional verification, but cannot ask for information already provided to the FFM. Such requirements must be consistent with the federal electronic verification rules. (For more information, see this related blog on state verification plans.)
While it’s important that state agencies and the FFM acknowledge the receipt of the electronic file transfers, more can be done to ensure that no one slips through the cracks in the process. A second transaction that reports the outcome of the eligibility determination (i.e., enrolled, denied, or withdrawn) could be coordinated to ensure that every application is not only successfully transferred but also acted upon. This means that either the FFM or the state would need to “own” the reconciliation process and take responsibility for identifying “unresolved” transfers – that is transfers for which no final decision has been recorded. Ideally, this would prompt further action to determine the status of the application and resolve any problems. I know first-hand such a system can work – we had it in place in New Hampshire to account for all transfers from Medicaid to CHIP. Far better to do something systemically than deal with unhappy consumers whose applications have been lost in the shuffle.
