The Centers for Medicare and Medicaid Services released on March 16 its final rule on changes to Medicaid eligibility to support policies that will expand insurance to millions of uninsured Americans and provide simple procedures to gain coverage. Medicaid expansion relies heavily on the use of information technology to automate and coordinate processes.
The Patient Protection and Affordable Care Act widens eligibility for Medicaid to adults with incomes 133 percent of the federal poverty level, or $14,856 for an individual and $30,656 for a family of four. The federal government will pay 100 percent of the cost of the Medicaid expansion for the first three years and at least 90 percent after that.
The final rule also makes it easier for eligible individuals and families to enroll in Medicaid and the Children's Health Insurance Program (CHIP) by cutting back on red tape and coordinating enrollment with the new Affordable (Health) Insurance Exchanges.
Families will be able to enroll in the appropriate coverage program through a single, streamlined online application, and states will have the benefit of reduced administrative costs, according to Marilyn Tavenner, acting CMS administrator.
"Today, too many uninsured Americans turn to the emergency room for care and can't pay their bills. Insuring more Americans will decrease the hidden tax states and consumers with insurance pay to cover the cost of caring for the uninsured," she said.
The 268-page final rule provides additional protections for consumers, as well as additional flexibilities and options for states, compared with the rule proposed in August 2011. CMS, which received 813 comments on the proposed rule, posted the final rule in a preview section of the Federal Register. It will be officially published March 23. The regulation is effective January 1, 2014.
The regulation builds on state efforts to modernize the eligibility, verification, enrollment and renewal systems to process Medicaid and CHIP applications and renewals for most individuals. Verification will rely primarily on electronic data matching sources, such as from the Social Security Administration.
"Our expectations are that these systems and technological capacities generally make it possible for real-time determinations of eligibility in most cases," CMS said in the rule, adding that it will also consider the pace and experience of states that are making investments in systems improvements and technology, which is supported by 90 percent federal matching payments through 2015.
In 2014, Medicaid, CHIP and the health insurance exchanges aim to coordinate to efficiently meet consumers' healthcare needs, improve quality and lower costs.
"We also intend to provide intensive technical assistance and support to states, as well as facilitate sharing and collaboration across states as implementation continues," CMS said in the rule.
In response to comments from states seeking additional flexibility in eligibility determinations, the rule provides two ways for exchanges to perform Medicaid-eligibility evaluations. One, the exchange can determine Medicaid eligibility based on the state's Medicaid eligibility rules and also decide eligibility for advance payment of premium tax credits; or second, the exchange can make a preliminary Medicaid eligibility assessment and rely on the state Medicaid and CHIP agencies for a final eligibility determination.
Timely and coordinated eligibility determinations are to be maintained under either approach, according to the rule.
CMS seeks comments on several provisions, including safeguarding information about applicants and beneficiaries; timeliness and performance standards for Medicaid, and coordinated eligibility and enrollment among insurance affordability programs.
The final rule does not deal with changes in the Federal Medical Assistance Percentage (FMAP) rates. A final FMAP rule will follow as a result of technical work with states on FMAP methods and income conversion.