Tech Tuesday: CMS State Eligibility Reviews to Focus on IT System Improvement

Each year, one-third of the states undergo payment error rate measurement (PERM) in Medicaid and CHIP, and all states must annually demonstrate the accuracy of their Medicaid eligibility determination process under the Medicaid Eligibility Quality Control (MEQC) program. However, the Affordable Care Act calls for significant changes to Medicaid and CHIP eligibility regardless of whether states expand Medicaid, which include:

  • Using modified adjusted gross income (MAGI) methodologies to determine income and household size
  • Deploying the HHS model or approved alternative single, streamlined application for all insurance affordability programs
  • Offering multiple paths to enrollment and renewal: online, phone, fax or mail
  • Accessing federal data services hub for electronic sources of eligibility verifications
  • Establishing electronic account transfers between the Marketplace (either federally-facilitated or state-based), Medicaid, and CHIP
  • Implementing data-driven processes to facilitate 12-month renewals

These changes are far-reaching and require the redesign of many Medicaid and CHIP business processes, as well as the development and implementation of new high-performing IT systems. So, business as usual is not the order of the day.

In light of these transformative changes, CMS is implementing an interim strategy for Medicaid and CHIP eligibility reviews under PERM and MEQC for 2014-2016. The regular review process for PERM managed care and fee-for-service payments will continue. However, for eligibility reviews, each state will participate in a Medicaid and CHIP Eligibility Review Pilot. These pilots will focus on:

1)   Providing assessments of the performance of new processes and systems in determining eligibility

2)   Identifying strengths and weaknesses in operators and systems that lead to errors

3)   Testing the effectiveness of corrections and improvements in resolving errors

That’s probably more than most advocates need to know, but what’s encouraging is that CMS will be taking a hard, internal look at how the new IT systems are performing in all states. All new systems have glitches that need to be debugged. By working with states to identify and remedy problems, rather than zinging them for errors, CMS is fostering a collaborative approach that will advance system readiness and effectiveness. All in all, consumers will be best served if experts who understand how eligibility is supposed to work can dig in and make sure the systems are working as expected.

[For more on this topic, view the Tech Tuesday blog series by Tricia Brooks or download the CCF-Consumers Union IT Toolkit.]

Tricia Brooks is a Research Professor at the Center for Children and Families (CCF), part of the McCourt School of Public Policy at Georgetown University.