By Martha Heberlein

The ACA requires states to use a single, streamlined application to determine eligibility for all health insurance affordability programs. Back in April, CMS released the model application that they will use in the federally-facilitated marketplaces (FFM). States can either adopt this for their own use or can use an alternative application that has been approved by the Secretary. Last week, CMS released guidance on what the alternative applications must include and the process for approval.

Customizing the Model Application:

There are a number of ways states can customize the model application in order for it to better fit their programs without needing CMS approval. For example, states can substitute state agency names, logos, and phone numbers – obvious changes states would want to incorporate to brand the application as their own. States can also eliminate questions that aren’t appropriate for their particular eligibility rules, such as questions regarding how long a child has been uninsured that would not be pertinent in a state that does not impose a waiting period in CHIP.

States can also make some slightly more substantial modifications to the model app without CMS approval, provided that they do not add any burden on the applicant. (CMS is mum on how – or if – this additional burden will be assessed.) For example, if a state chooses to address a particular issue (like medical support) post-eligibility, the relevant questions can simply be dropped from the model application. Additionally, if there is a state option that is not supported within the FFM, such as coverage for family planning services, these questions may be added without CMS approval.

Alternative Applications:

Regardless of whether a state uses its own application or the model developed by CMS, it must only ask questions that are necessary for determining eligibility; should minimize the burden on applicants; and rely first on electronic data sources prior to asking for any documentation. If a state does decide it wants to develop a true alternative application, it must request the information necessary to determine eligibility in Medicaid, CHIP, and for Qualified Health Plans (QHPs) sold with or without a premium tax credit on the exchange. That means questions like those relating to affordable, minimal value, employer-based coverage that are only relevant for APTC eligibility will need to be included. On this and other particularly thorny issues, states that are developing their own application may want to look to the consumer-tested approach in the model app for possible ideas.

Multi-Benefit Applications:

The vast majority of states currently have a multi-benefit application that allows families to apply for more than one human services program, such as Medicaid, SNAP, and TANF, with a single app. States are able to continue this approach under the ACA as long as they provide applicants with a health-only application as well. Like any other alternative application, a multi-benefit app must ask the relevant questions for all health insurance affordability programs as well as clearly indicate which questions are optional for determining eligibility for health insurance coverage.

Working through the Medicaid and CHIP Learning Collaborative, CMS has pulled together some tables that may be helpful for states considering updating their integrated applications. One way to think about it – all the appropriate questions for determining eligibility under the current rules are already on a state’s existing multi-benefit app. States can therefore focus their efforts on the changes made to Medicaid eligibility under the ACA by adding questions to determine income under the MAGI rules and any APTC-specific questions. However, accomplishing this in a user-friendly and streamlined way may be easier said than done!

Approval Process:

While it’s pencils down in DC and no additional changes will be made to the model app used in the FFMs, state advocates may have an opportunity to influence how consumers will apply for health coverage and other human services benefits in states choosing not to adopt the model application. The review and approval of alternative applications will be done through State Plan Amendments, so keep your eyes out for new SPA pages where states will indicate whether they will be using the model application or an alternative. Given that states have needed to make many programmatic and system decisions to prepare for open enrollment without this guidance, CMS acknowledges the condensed timeline states are facing for securing approval of their applications. As such, they will allow conditional approval of alternative applications for 2014 and may offer an expedited approval process if necessary. Advocates should monitor their state’s “conditional approval” and the proposed timeline for addressing any concerns that CMS raises during the review to be sure that their state is in compliance with the streamlined application and enrollment process envisioned under the ACA.