Health Advocate: Health Reform Moving Forward: Recent Medicaid and Exchange

Executive Summary

This issue of NHeLP's Health Advocate provides an update on health reform implementation, focusing on recent Medicaid and Exchange regulations.

In seventeen months, the first open enrollment period for health insurance exchanges begins. In March, the Centers for Medicare & Medicaid Services (CMS) issued regulations addressing the exchanges, the Medicaid expansion that occurs in 2014, and the coordination required between exchanges, Medicaid, Children?s Health Insurance Programs (CHIPs), and Basic Health Plan (BHP) programs. These rules provide significant details for those working on full implementation of health reform. But they also raise concerns for those who work on behalf of low-income and underserved populations.

A major goal of health reform is to create a streamlined process to determine the eligibility of applicants for a range of health insurance programs and financial assistance. Under the new regulations, a single coordinated application will collect sufficient information to determine eligibility for most government-sponsored insurance programs (with the notable exception of Medicare). Between now and 2014, implementing this ?one stop? application will require both significant coordination between federal and state agencies and across-the-board improvements in information technology. If the pieces of the puzzle are not ready by 2014, the result could be confusion, frustration and the inability of millions of individuals to obtain health insurance.

Medicaid and CHIP Eligibility and Application Regulations
The Medicaid regulations address requirements for state Medicaid and CHIP programs to streamline their application and eligibility processes to coordinate with the new exchanges, including:
  • condensing income standards for existing Medicaid eligibility categories;
  • determining eligibility under the new category enacted in the ACA; and
  • ensuring coordination among and between Medicaid, CHIP and the exchanges.
Approximately 17 million individuals will become Medicaid eligible in 2014 through a new Medicaid category that covers most adults under 138% of the federal poverty level (FPL) who are not already eligible. States will evaluate income using a ?modified adjusted gross income? standard (MAGI) using available federal databases linked through a federal ?hub? (including information from the IRS, SSA and the Department of Homeland Security). MAGI-eligible individuals will receive benefits based on certain defined ?benchmark? plans that may offer a limited package of benefits.

Many individuals who apply under MAGI may also be eligible for ?traditional? Medicaid (i.e., are elderly, pregnant, have disabilities or otherwise qualify) and require evaluation using current Medicaid eligibility rules. This will likely include individuals with disabilities or those who meet a definition of ?medically frail.? Eligibility for traditional Medicaid brings with it the ?traditional? package of covered benefits which, in many states, will be broader than services available to the MAGI population. While benefits offered in traditional and MAGI Medicaid may have significant differences, states can offer both groups the same benefits. A single set of benefits for all Medicaid enrollees will reduce state oversight and administrative costs.
NHeLP Recommends: States should adopt similar benefit packages for MAGI and traditional enrollees offering the broadest scope of services to meet enrollees? needs.

Those eligible pursuant to MAGI will automatically receive Medicaid for one year. Unfortunately, a state may limit eligibility under other categories to less than a year (although enrollees can apply to renew their eligibility). This disproportionately affects non-MAGI enrollees, such as children and people with disabilities, who may have to go through multiple redeterminations each year. Multiple redeterminations result in inefficient and wasteful administration. Since every individual must have health insurance after 2014, continuous eligibility for every Medicaid enrollee for 12 months would result in more efficiencies and cost-effectiveness.
NHeLP Recommends: CMS and advocates should strongly encourage states to adopt 12-month continuous eligibility for all Medicaid and CHIP enrollees.

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