From September 7-9, CMS hosted an intense three-day conference on the proposed eligibility rules for Medicaid and the Exchanges that CMS (here and here) and IRS released in August. The agencies presented a full menu of detailed information on the rules.
The breakout sessions and plenaries (not to mention a state-only meeting and an open session of the Eligibility Technical Advisory Group which closed the conference) conveyed far more information than I can recap here, but I’ll attempt to digest some key takeaways.
Do You Have Any Questions About the Menu?
The rules set out a new national framework for health coverage, but presenters frequently mentioned a desire to leave states with flexibility to design systems for their particular needs. A factor influencing that conversation is that, as one conference presenter put it, there may simply not be enough time for states to fully explore what all their options are – in order to meet the ACA deadlines, states may need the federal government to be more prescriptive in telling states how they ought to proceed.
The broad strokes of the rule – developing a system to deliver simple, seamless, and affordable coverage to all Americans – is clear enough (and was a mantra that CMS started with and repeated throughout the meeting), but there are a lot of questions to answer on the way there. Key questions raised by conference attendees included:
- Household income (MAGI): How should states operationally reconcile the Exchanges’ use of annual income with Medicaid’s requirement to continue using current monthly income? What are the consequences of moving to the IRS definition of income, which excludes things like Social Security and child support payments? What method should states use to convert existing disregards into MAGI-equivalent income levels?
- Verification Systems: What is the federal “data hub” going to look like, and what information will be obtainable, particularly in regard to IRS data about income? How feasible is real-time determination of eligibility, if it’s unclear where to obtain electronic sources of current monthly income?
- Claiming Federal Funds (FMAP): How does the state figure out who’s “newly eligible” versus previously eligible, particularly in complicated cases such as states who currently cover optional populations of people with disabilities? How do they ask questions that allow them to collect all the information needed to make a determination, and still comport with the rule’s goal of having a streamlined application?
- Integration with Exchanges: What does integration between Medicaid, CHIP and a state Exchange (or a federal Exchange) look like, exactly? How does the need to integrate Medicaid with the Exchanges interact with many states’ previous efforts to integrate Medicaid enrollment with programs like SNAP, which are not health-insurance-focused, and may have differing requirements?
To be clear, a lot of thinking has been put into potential answers for all of these questions. Some are proposed in the rules, and others, such as a method for conversion of income disregards, are still being worked on. It is important that the federal agencies get feedback from states on the feasibility of those answers.
The Moveable Feast
CMS also made it clear that this conference was just an appetizer, and that the discussion would be continuing in a variety of venues.
- Within a few weeks, presentations from the conference will be posted online.
- CMS will soon be launching a redesigned webpage – Medicaid.gov – that will provide streamlined access to all things Medicaid – look for news of the launch in the coming months.
- CMS will work with Treasury to identify existing IRS training materials to provide Medicaid officials with a better grounding in tax policy for their MAGI work.
- More guidance and information on items described in the rules is coming. For example, CMS is preparing a “map” that explains in more detail the crosswalk between existing mandatory and optional coverage groups and the four streamlined groups outlined in the NPRM.
- Most importantly, CMS and IRS need written comments on the proposed rules by October 31. Go to https://www.regulations.gov/ to submit your comments.
What is your state’s reaction to the new eligibility rules? Share your state’s work on your state’s milestone page on State Refor(u)m. To engage in a cross-state discussion about the proposed rules and this milestone visit State Refor(u)m’s national discussion page.