Flipping the Script on State Eligibility Processes

Like many others working on health reform implementation, my colleagues and I at NASHP spent the better part of our summer vacation reading the 3 new eligibility rules that were released byCMS, CCIIO, and IRS on August 17. For those of you still reading or just looking for a really good analysis, we recommend the recent Robert Wood Johnson Foundation-funded State Networkanalysis by Deborah Bachrach and her colleagues at Manatt Health Solutions and the series (here,here, and here) of Health Reform GPS Updates.  There are so many issues in these rules to unpack, like our summer vacation suitcases, that it was hard to pick just one. One big idea that hit home was how much of a radical departure from prior state eligibility and enrollment approaches these rules represent.
Since the program’s inception, Medicaid eligibility rules have put the burden on individual applicants to prove eligibility through paper documentation.  Even as some states started using electronic data to verify individuals’ eligibility, electronic verification is usually used as a secondary resource to confirm eligibility and not often used to document eligibility first before states ask for information.  At its heart, the eligibility process has been about whether an individual is eligible or not based on verification documents, with the default being a coverage denial.
The proposed Medicaid/CHIP eligibility rules prescribe a streamlined approach to verification that completely re-imagines the relationship between applicant and state agency.  Key provisions include:

• States using electronic data sources “to the maximum extent possible” to verify eligibility.
• A new federal data hub will provide states with one-stop access to federal data for verifications, including at a minimum Social Security numbers and citizenship (from the Social Security Administration), immigration status (from Department of Homeland Security), and income data (from the IRS) [42 CFR 435.949].
• States can rely on self-attestation for all eligibility criteria except citizenship and immigration status.  Self-attestation will be the only form of verification states can use for pregnancy unless the claims data doesn’t support the pregnancy claim. States are still obligated to conduct data matches with SSA, IRS or other federal databases and to adhere to program integrity protocols.
• If eligibility data matches differ from information provided by the applicant, states will have the flexibility to determine whether the information provided is “reasonably compatible” with the data the state has.  “Reasonable compatibility” means that the information the applicant provided is relatively consistent and any differences won’t have a significant impact on the eligibility decision.
• States will have new flexibility to determine which sources of data and how often to use electronic data sources to support an eligibility determination based on the state’s experience and the appropriateness of the data.
• The verification process will be integrated with the overall screening and seamless enrollment process promised in the rules, under which any individual found ineligible for one program will be automatically screened and enrolled into a more appropriate program (i.e., Medicaid, CHIP, Basic Health Plan (if applicable), qualified health plan (QHP) with tax credit and subsidies, or QHP).

These changes basically flip the script on state eligibility processes in at least three key ways.  First, the rules clearly shift the responsibility from the individual to the state to verify eligibility.  Second, for the first time, the hierarchy of data sources is rearranged, making electronic data and self-attestation more important than paper documentation.  Finally, the rule shifts the eligibility paradigm for states from whether an individual is eligible to where the individual belongs in a continuum of coverage options that the state manages or facilitates.
While it will take a while for states and their federal partners to iron out all the implications of this new approach, there are a number of reasons states may welcome these changes with open arms:

1. Current systems are woefully outdated and most are not using available data to verify eligibility. The rule will require states to update IT systems to enable electronic data verification, which will ultimately improve their Medicaid systems.
2. State methods of seeking documentation from individuals are inefficient, resource-intensive, and time-consuming, in part due to the difficulties and delays associated with obtaining paper verifications.  Under the rules, states will be able to harness existing data to move applications through the eligibility process much faster in most cases, which should decrease the administrative burden of processing applications.
3. CMS provides new flexibility to states, eliminating some current prescriptive requirements and deferring to state judgment on the reasonable compatability standard to resolve inconsistencies in data verifications while still holding states accountable for program integrity.  This outcome-driven approach can allow states greater freedom in running their programs
4. The rules create an opportunity for states to emphasize coverage as a primary goal and, where needed, to shift agency culture.

Of course, important questions about these new verification rules remain.  There remains a lack of clarity about how the process and hierarchy of information should work.  Without stronger guidance and given states’ fear of program integrity reviews, many states may feel inclined to fall back on paper documentation as the default rule where discrepancies in the data arise. States also may have trouble balancing the need for real-time decision-making that defers to attestation and the ongoing need for program integrity.  And states and their federal partners may want to think about more efficient ways to obtain documentation nationally (e.g., can federal agencies help states obtain more current income data at the national level?).
Still, these rules promise a major change in the eligibility landscape for states that is long overdue, giving states the chance to turn the page on their old systems and create a blockbuster hit in 2014.  The question is, are states and their federal partners ready for their close-up?
What is your state’s reaction to the new eligibility rules? The comment period remains open until October 31, and there are many areas of the regulations where the federal agencies are actively seeking input from states.   What are your state’s plans to use technology and systems solutions to eliminate unnecessary paper-based processes? Share your state’s work on your state’s Eligibility and Enrollment 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.
Stay tuned for more blogs on eligibility topics from State Reforum, including a blog about the CMS Eligibility Conference coming soon!