Before the holidays, MACPAC and its contractor, SHADAC, (the State Health Access Data Assistance Center at the University of Minnesota) released findings of a study that examined the status of the new data-driven enrollment and renewal processes enacted as part of the Affordable Care Act. The case studies report on how six states – Arizona, Colorado, Florida, Idaho, New York and North Carolina – took different approaches to streamlining Medicaid eligibility processes. The states were chosen to represent diversity across a range of characteristics including Medicaid program size, adoption of the Medicaid adult expansion, health insurance marketplace type, geography, current enrollment and renewal practices, and political climate. A key difference between the states was whether or not they designed their systems to facilitate real-time “no-touch” enrollment and renewal or continued to rely on state/county workers to manage the eligibility process with enhanced access to electronic data.
The studies highlight several common themes across states:
Multi-benefit online applications enhance access to programs but back-end eligibility systems are complicated. Multi-benefit applications provide access to health programs, as well as other benefits such as food assistance or child care subsidies. A key benefit of combined applications is that they help potential beneficiaries learn about the full range of benefits that they or their children may be eligible to receive. And although it makes it easier for applicants to enroll, the back-end eligibility systems are complicated. While most states have deployed new technology to determine eligibility for Medicaid and CHIP, the eligibility systems for other programs are fragmented and often outdated.
Electronic verification enables states to achieve high rates of real-time eligibility determination and automated renewals. Whether enrollment and renewal are achieved with or without eligibility worker intervention, most respondents (which included a range of state officials and other stakeholders) remarked that the efficiencies gained through data interfaces reduced administrative costs and fluctuations on and off Medicaid (also known as churn).
Robust rules engines at the core of the eligibility systems are critical but workers still need to understand policy. High-performing systems can efficiently automate the varied and complex eligibility rules across programs, but eligibility workers still need to understand policy so they can assist families with enrollment and answer questions about eligibility. Eligibility workers who understand policy are also an important quality control check in detecting potential system glitches.
Complex and varying eligibility rules across programs complicate the integration of Medicaid and other programs. States reported that it is challenging to accommodate the differing program rules that range from how income is counted to whether stricter verification is required, such as reporting work hours. Developing a single streamlined application that collects information needed for all programs in an easily understood way is also a struggle for states.
Demand for personalized assistance remains strong despite streamlined processes. Respondents uniformly agreed that streamlined processes and combined applications are helpful to people. However, in-person assistance is still in high demand particularly for specific populations such as immigrant families or individuals with lower computer literacy.
The study demonstrates that efforts to accurately and efficiently enroll and renew Medicaid eligibility require a continuous improvement approach. Common areas of ongoing activity include monitoring Medicaid and related policy changes (such as waivers and reductions in navigator funding to provide consumer assistance); improving beneficiary communication; and continuing to advance eligibility system infrastructure to improve consumer access and integrate Medicaid and non-health programs.
Being aware of the complexity of eligibility systems and processes across states, I was not surprised by the findings of the study. It is clear that Medicaid remains a state-administered program with each state establishing its own priorities and processes within federal parameters. But states strive to manage Medicaid eligibility and enrollment as efficiently and accurately as possible.
Actions that the current administration has taken to waive federal standards and undermine access to consumer assistance won’t help in that regard. And state efforts to re-integrate system eligibility for multiple benefits will certainly be stalled by the expiration of 90 percent federal funding at the end of 2018.
Until you work in a hands-on environment of Medicaid eligibility, it is difficult to fully grasp the complexity of the processes and systems needed to effectively support the Medicaid enterprise. Legislators can easily believe that restricting Medicaid eligibility equates to government efficiency but those who administer Medicaid understand that such restrictions are usually detrimental to efforts to improve government efficiency and wind up actually increasing administrative costs.
An assessment and synthesis of the MACPAC study prepared by SHADAC and the related MACPAC issue brief can be accessed here. I encourage stakeholders in the states featured in this study to read your state’s case study as noted in the links above.