Priority Area 3: Simplify and Integrate Eligibility Systems

Dramatic simplification of eligibility is the only way to achieve the promise of near-universal coverage embodied in the federal law. To put it bluntly, 36 million Americans cannot be enrolled in Medicaid or the new exchanges by relying upon what in most states is a county-based eligibility platform designed around the cumbersome and intrusive processes of the welfare eligibility system. Eligibility systems in most states rely upon outdated technology and are expensive and slow to modify.

The federal law effects a tremendous simplification in Medicaid eligibility—moving to standards based on modified adjusted gross income as defined in the tax code. This simplification meshes nicely—at least in theory—with the simplified income tests for exchange-based subsidies. To make this work in practice, states must work out myriad issues that coordinate the flow of eligibility and enrollment information among Medicaid, CHIP, and the exchange. They must develop and refine data sharing between these entities and the federal government for information on income and citizenship. These information streams must come together in real time to provide potential enrollees with clear choices regarding their coverage options.

States have learned a great deal about effective outreach, enrollment, and retention of people eligible for coverage—but part of what they have learned is that those tools are only effective in the context of an improved eligibility system. With guidance from the federal government, states must completely redesign their eligibility systems and processes to assure seamless transitions as families’ incomes rise and fall; families are formed, grow, or dissolve; part time, seasonal, and migrant workers change status; and people move from one part of the state to another—or to another state entirely. This redesign must account for the need to continue administering fairly complex eligibility standards for some categories, such as people with disabilities, and for the efforts many states have made in recent years to offer single entry points for access to a broad range of social services, including the Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) and child care subsidies. This is a massive undertaking. If done well, it holds the promise of incredible efficiencies and dramatic improvements in customer service and, ultimately, access to care.