Say Ahhh! readers know that I have long been frustrated at the delay in releasing state-level performance indicator data in Medicaid and CHIP. While CMS has posted enrollment and application data for some time, data on the remaining performance indicators – which were announced in September 2013 (that’s more than five years ago!) – have yet to be reported publicly. The release of application processing times is a welcomed step toward more transparency in Medicaid and CHIP. So what did we learn in the report?
As states advance electronic verification of Medicaid and CHIP eligibility, it is expected that new and renewal applications will be processed more efficiently and quicker. States have up to 45 days to make eligibility determinations for MAGI-groups – that includes children, pregnant women, parents and expansion adults. But with high performing Medicaid IT systems and electronic verification, determinations can occur instantaneously or in real time (defined as 24 hours). The performance indicators require states to report the share of eligibility determinations made in several time buckets: in 24 hours, one – seven days, eight – 30 days, 31 – 45 days, or over 45 days. There is a table that reflects the share of applications that are processed in those groupings on a state-level basis for the months of February, March, and April 2018. The report also includes the state map (below) reflecting what share of applications are processed within 7 days based on quintiles (0 – 20%; 20 – 40%, etc.).
The good news is that nationally, almost 50 percent of all determinations (in the 42 reporting states) are made in 7 days or less. The standout states in timely processing include Alabama, Connecticut, the District of Columbia, Idaho and Maryland, where approximately 75 percent of applications or more are processed in real time (defined as 24 hours). The states in serious need of improvement are Alaska, Georgia, Illinois, Maine, Missouri, Ohio, and Virginia where at least 25 percent and up to over 50 percent of determinations are taking more than 45 days – putting them out of compliance with federal standards. Nine states (AR, CA, ID, LA, MN, NV, NY, SC, TN) either did not report data or the data did not align with CMS specifications.
So what can advocates and consumer assisters do in states where backlogs and delays in processing eligibility and delays impact timely access to health care for children and low-income families? First of all, it’s important for families to know about retroactive coverage. If new enrollees or applicants have incurred medical bills in the 90 days before the date their application is submitted, they may be eligible for retroactive coverage. In those cases, eligibility for the retro period must be verified.
Additionally, all states should have hospital presumptive eligibility (PE) programs, whereby hospitals may be engaged in working with patients to temporarily enroll eligible children, pregnant women, and adults in Medicaid while the regular application is processed. Some states have also adopted presumptive eligibility for children and pregnant women using other organizations (known as qualified entities), such as federally qualified health centers, to temporarily enroll eligible individuals. To check if your state has PE in place, see table 12 on page 49 of our annual 50-state survey on Medicaid and CHIP. Last but not least, advocates and consumer assisters can provide direct feedback on how eligibility is working in the field. This can assist the state in identifying systemic issues or glitches that may contribute to backlogs or even denials of coverage for eligible individuals.
More detailed information about the Eligibility and Enrollment Performance Indicators, including the standardized definitions, can be found here. More detailed information on state policies and practices that influence these data, can be found here.
