Figure 1

In addition to managing an expanded Medicaid

population, states must convert to the new MAGI

methodology on April 1, 2015.

Are you maximizing your Medicaid Renewals and Enrollments in 2014?

Leveraging CMS’ Strategies for facilitating 2014 Enrollments

Under the Affordable Care Act, every state must simplify the systems that are used to enroll eligible

people in the Medicaid and Children’s Health Insurance Programs (CHIP) on January 1, 2014. For

many states, this also means a new group of low-income adults will also become eligible for Medicaid

coverage.

While this represents an unprecedented opportunity for states to modernize their systems, it also

presents many challenges as states will simultaneously be enrolling large numbers of people who

become eligible all at once, after the Open Enrollment Period that is determined by the state.

Policy makers should prepare to handle uncertainty and many contingencies in Medicaid expansion

under health reform, including the risks and program challenges new enrollees bring. While some of

the new enrollees may be similar to the population states already serve, a newly eligible

group—childless adults under 65—will have different characteristics as well as different program and

service requirements. To accommodate this expansion properly and ensure a smooth transition, it’s

important that Medicaid agencies understand when and how the ACA expansion will occur.

ACA Go-Live, Year 1

As the ACA is implemented, the Medicaid population will simultaneously expand and be

migrated to the new Modified Adjusted Gross Income (MAGI) methodology. Under reform,

eligibility for Medicaid and subsidies in the Exchange will be based on MAGI without an asset test.

Moving to MAGI changes the rules about what income counts and how households are defined. This

national standard is a major simplification from present practice in which each state Medicaid

program has its own methodology for counting income and resources. The essential timeline for ACA

implementation includes:

1. From October 1, 2013 through December 31,

2013, agencies take applications for the

expanded Medicaid program using the MAGI

Methodology with resulting enrollments

becoming effective on January 1, 2014.

2. On January 1, 2014 the ACA goes live and the

expansion enrollments become effective,

thereby expanding state Medicaid programs.

3. From January 1, 2014 through March 31,

2013, the MAGI Methodology cannot be used

to determine renewal eligibility for “current

beneficiaries” when conducting their annual

renewal evaluations.

4. Starting April 1, 2014, states begin using the MAGI Methodology to determine annual renewal

eligibility for the pre-MAGI “current beneficiaries.” The process of determining eligibility using

Figure 2

Following the ACA implementation state Medicaid agencies are faced with an enormous annual renewal

burden on January 1 when the newly enrolled expansion population renewals become due. Initial estimates

suggest this might amount to as much as 30% of the entire Medicaid population.

MAGI on “current beneficiaries” is completed by March 31, 2015.

5. Steady State will not be reached until Fiscal Year 2016.

Out-Year Annual Renewal Challenge

States face an increase in their annual Medicaid renewals one year after the ACA is

implemented. Because new ACA expansion enrollments commence on January 1, 2014, a spike in

annual renewals will occur on January 1 each year, starting in 2015. In January, 2015, the states

must complete annual renewals for Medicaid individuals who were added in January, 2014, adding

substantially to states’ workloads. Additionally, because current beneficiaries cannot be renewed

using the MAGI methodology until April, the January spike may be followed by a two month lull

before resuming renewals at a rate that could double the normal monthly renewal load.

Specific Targeted Enrollment Strategies

In its 5/17/2013 State Health Official (SHO) Letter, CMS outlined five specific targeted

enrollment strategies that states can use to facilitate Medicaid and CHIP Enrollments and

Renewals in 2014.

These Enrollment Strategies provide important advantages both for uninsured individuals as well as

states. They target individuals likely to be eligible for Medicaid, and for whom eligibility information

is already in the state’s files. As a result, states can use these strategies to easily identify and enroll

eligible individuals without requiring them to complete a new application. These strategies can also

be used to facilitate future renewals. As CMS suggests, these strategies help to alleviate the

increased administrative demands on the state’s eligibility and enrollment systems that are expected

during the Open Enrollment Period (10/1/2013 – 1/1/2014) and the first quarter of 2014.

Following are the five strategies noted in the 5/17/2013 SHO Letter:

1. Implementing the early adoption of Modified Adjusted Gross Income (MAGI)-based rules.

2. Extending the Medicaid renewal period so that renewals normally occurring during the first

quarter of 2014 (January 1, 2014 – March 31, 2014) occur later.

3. Enrolling individuals into Medicaid based on Supplemental Nutrition Assistance Program

(SNAP) eligibility.

4. Enrolling parents into Medicaid based on their children’s income eligibility.

5. Adopting 12-month continuous eligibility for parents and other adults.

States can employ these enrollment strategies in order to dramatically mitigate the

post-ACA implementation renewal spikes. These strategies, coupled with other options such as

aligning Medicaid renewals with other program enrollments (e.g. SNAP & TANF) and structuring

policies to fully enable “No-Touch” renewals can help to smooth out this increase in renewal activity

and lessen its impacts on their Medicaid organizations.

While states may be hard-pressed by the many items on their Medicaid expansion task list, one item

can’t be put off: planning for smooth program operations in year 1 and the out-years.

This series of white papers analyzes each of these enrollment strategies and outlines the associated

benefits as well as some of the operational impacts of each.

Figure 3 During the 2013 Open Enrollment Period, states must use

two sets of rules to process new applications and 2013 Renewals.

and New Applications

Strategy 1 – Implementing the early adoption of the Modified Adjusted Gross

Income (MAGI)-based rules.

The new Modified Adjusted Gross Income (MAGI) methodology differs from the Medicaid eligibility

rules that are currently in effect. Under the Affordable Care Act, states cannot simply replace their

current eligibility rules with MAGI. They must gradually transition to the new methodology.

Beginning October 1, 2013, states must use two sets of Eligibility Rules

During the Open Enrollment Period (October 1, 2013 through December 31, 2013), states must be able

to process new Medicaid applications with either MAGI or the current Medicaid rules. However, as

shown in Figure 3, states can only use the current Medicaid rules for renewals of their existing

Medicaid population that occur during

this period.

As a result, the states’ eligibility

systems and operational processes

must use two different sets of rules for

new Medicaid applications and

renewals of the existing Medicaid

population that occur during the Open

Enrollment Period.

Avoid using two sets of rules by adopting MAGI early

Strategy 1 allows states to fully adopt the MAGI methodology early during the Open Enrollment

Period for both 2013 Renewals as well as new applications. This allows states from having to operate

with two different sets of rules and enables them to better coordinate the new open enrollment process

with their traditional renewal process.

This strategy also allows states to better serve their existing beneficiaries who are found to be

ineligible. With synchronized processes, instead of simply terminating an ineligible beneficiary’s

coverage, states can immediately use the MAGI methodology assess the person’s eligibility for 2014

Medicaid or one of the state’s Qualified Health Plans.

What CMS requires

According to CMS’ 5/17/2013 State Health Official (SHO) Letter, in order to implement Strategy 1, a

state must have a time-limited section 1115 waiver of section1902(a)(17) of the Social Security Act

(the Act). This will allow them to use the new MAGI methodology for determining Medicaid

eligibility for people seeking coverage that will take effect prior to January 1, 2014.

CMS advises states who are interested in employing this strategy to also discuss this with CMS

during their regular State Operations and Technical Assistance (SOTA) calls.

Figure 4 During the first quarter of 2014, states must use two sets

of rules to process 2013 Renewals.

Strategy 2 – Extending the Medicaid renewal period.

The Affordable Care Act contains a provision that protects current Medicaid recipients from losing

their eligibility solely because of the new MAGI methodology and new household composition rules

that are implemented in 2014. This provision

focuses on renewals that occur during the first

quarter of 2014 (January 1, 2014 through March

31, 2014) and requires states’ renewal processes

to test eligibility with two sets of rules.

For first quarter of 2014 renewals, states must use two sets of Eligibility Rules

During the first quarter of 2014 (January 1, 2014 through March 31, 2014), states will only use the

MAGI methodology for all new Medicaid applications. However, as shown in Figure 4, for renewals

of their existing Medicaid populations that occur during this period, states must also be able to use the

current Medicaid rules. Because of the

protection provision, if a beneficiary is found

to be ineligible because of the MAGI

methodology, the state must conduct

another eligibility assessment with the

current pre-MAGI rules that are in place

today.

As a result, the states’ eligibility systems

and operational processes must be able to apply both current pre-MAGI rules and MAGI rules to all

beneficiaries whose renewal date falls between January 1 and March 31, 2014.

Avoid using two sets of rules by simply deferring 1st Quarter 2014 Redeterminations

Strategy 2 allows states to extend the Medicaid renewal period for beneficiaries whose coverage is up

for renewal in the first quarter of 2014. This enables state to delay renewal dates so that they occur

after March 31, 2014, the last date of the Affordable Care Act’s protection provision.

This frees the states from having to use two sets of eligibility rules for redeterminations that occur

from January 1, 2014 through March 31, 2014 and thereby limit of the risk of mistakes and

inefficiencies. As a result of this strategy, states would not have to conduct renewals in the first

quarter of 2014 and need only use the MAGI methodology rules for all renewals that are scheduled to

occur after March 31, 2014.

As part of Strategy 2, states would be able to define how the delays would occur. For example, using

a delay of 90 days for this period would result in renewals that are scheduled for January 2014 to

occur in April 2014, renewals slated for February 2014 would occur in May 2014, and renewals

scheduled for March 2014 would occur in June 2014. This flexibility allows states to evenly

distribute these rescheduled renewals in a way that matches the capacity of the organization.

What CMS requires

According to CMS’ 5/17/2013 State Health Official (SHO) Letter, Section 1902(e)(14)(A) of the

Affordable Care Act, added by section 2002 of the Affordable Care Act, generally requires the use of

the MAGI-based income methodology to determine Medicaid eligibility, and also allows for waivers “as

are necessary to ensure that states establish income and eligibility determination systems that protect

beneficiaries.” As a result, states that are interested in using Strategy 2 can request such waiver

authority under section 1902(e)(14)(A) of the Act on a time-limited basis. The Strategy 2 waivers are

not subject to transparency rules and, as a result, no additional procedures are required by federal

law.

CMS advises states who are interested in employing this strategy to also discuss this with CMS

during their regular State Operations and Technical Assistance (SOTA) calls.

Strategy 3 -- Enrolling individuals into Medicaid based on Supplemental Nutrition

Assistance Program (SNAP) eligibility.

In general, most people who are currently enrolled in SNAP would be eligible for Medicaid. This is

because, in order to qualify for SNAP, a household’s gross income cannot exceed 130 percent of the

federal poverty level

SNAP is a trusted and complementary program

In many states, income data from SNAP is considered to be

reliable because it is stringently verified and in most cases is no

more than 6 months old. As a result, SNAP income data is often

used to renew Medicaid eligibility.

Use SNAP data to quickly enroll SNAP participants who are eligible for Medicaid

Strategy 3 allows states to facilitate the Medicaid enrollment of non-elderly, non-disabled SNAP

participants who are financially eligible with the new MAGI methodology. States can benefit from

this strategy because it allows them to enroll eligible SNAP participants directly into Medicaid

without having to conduct additional determinations that are based on the new MAGI rules.

From a systems and operational perspective, Strategy 3 helps states who are implementing new

eligibility systems. Since it provides a trusted and direct path for enrolling people in Medicaid,

Strategy 3 helps states to relieve some of the pressure and increased volume that will be placed on

their new systems and processes beginning on October 1, 2013.

From an outreach and customer service perspective, this strategy also helps inform SNAP

participants of their Medicaid eligibility and provides them with a clear and easy way for them to

enroll. Since SNAP participants already have trusted relationships with their states, with this

strategy, they do not have to work with an approved Navigator who may be unknown to them or visit

their state’s marketplace to apply for Medicaid. This is because much of their trusted SNAP data

satisfies most of the information that is required by the new single, streamlined application for

Medicaid.

Operational Considerations

In order to enroll eligible SNAP participants, states must still obtain the minimum required amount

of information for a Medicaid application. In addition to the SNAP application data that is already

on file and can be easily transferred to the Medicaid program, this includes a signature that meets the

requirements of the Affordable Care Act.

In its 5/17/2013 SHO Letter, CMS outlined the following options that could be used to attain this

signature from eligible SNAP participants:

a. The household applies for Medicaid through the SNAP application by using a check-box that

has been added to the SNAP enrollment form.

b. The household applies for Medicaid at its SNAP recertification by using a check-box that has

been added to the SNAP recertification form.

c. Non-elderly, non-disabled household members receive a Medicaid card at the time the SNAP

household is notified of SNAP enrollment or recertification. A phone call or online

acknowledgement by an adult who receives a card constitutes a Medicaid application and

“activates” the card.

d. Non-elderly, non-disabled household members receive a Medicaid card at the time the SNAP

household is notified of SNAP enrollment or recertification. These household members

indicate that they are applying for Medicaid when they go through the process of selecting a

managed care plan. This process also activates the Medicaid card.

Some states have also developed a series of notices that informs SNAP participants of their eligibility

for Medicaid and asks if they would like to be enrolled in Medicaid. SNAP participants who sign the

notice, indicate that they would like to be enrolled, and return the notice to the state are then enrolled

into Medicaid. (As part of this normal Medicaid enrollment process, these participants also receive a

formal Notice of Eligibility as well as a Medicaid card.)

What CMS requires

According to CMS’ 5/17/2013 State Health Official (SHO) Letter, in order to implement Strategy 3, a

state must request a waiver under section 1902(e)(14)(A) authority to allow the state to enroll eligible

non-elderly, non-disabled SNAP participants who are not already enrolled in Medicaid.

The state will have to explain why such a procedure is necessary to help implement its eligibility and

enrollment system as well as meet its administrative responsibilities for the program. In addition to

this, the state will have to define the timeframe during which it will use this strategy and must

explain how it will obtain the minimum requirements for an application to be enrolled in Medicaid

under 42 CFR 435.907, including the requirement to obtain a signature, whether physical, electronic

or telephonic, that complies with the requirements under 42 CFR 435.907(f).

Strategy 4 -- Enrolling parents into Medicaid based on children’s income eligibility

All states cover some parents through Medicaid, but the eligibility threshold for parents is often very

low. When the Affordable Care Act (ACA) is fully implemented, Medicaid eligibility will be extended

to most adults, including parents, with incomes up to 138 percent of the FPL.

For states who are expanding their Medicaid programs by adding the new adult group under

1902(a)(10)(A)(i)(VIII) of the Affordable Care Act, a large number of parents whose children are

already enrolled in Medicaid are likely to meet the new MAGI-based income eligibility standards.

Many parents of children currently enrolled in Medicaid will be eligible for coverage in

states that expand their Medicaid program

With these facts in mind, CMS is offering states an opportunity to facilitate the Medicaid enrollment

of parents whose children are currently enrolled in Medicaid and who are likely to be

Medicaid-eligible. This will help states to provide an efficient way to enroll adults in Medicaid and

will relieve some of the operational pressures that will occur as states progress through the initial

phases of implementing new eligibility and enrollment systems.

Strategy 4 enables states to facilitate the enrollment of parents of children currently enrolled in

Medicaid. States would have to identify all families with incomes at some level below 138 percent of

the federal poverty level who are likely to be Medicaid-eligible. Using a standardized and approved

process for converting the states’ current Medicaid effective income standards to new MAGI-based

income standards will help the states to identify income levels for households that are likely to be

Medicaid-eligible.

Operational Considerations

In order to enroll eligible parents, states must still obtain the minimum required amount of

information for a Medicaid application. In addition to the child’s Medicaid application data that is

already on file and can be easily transferred to the Medicaid program, this includes a signature as well

as additional non-financial information that are necessary to make an eligibility determination.

CMS has specified that states could use a combination of actions similar to the ones described in

Strategy 3 to collect this additional non-financial information and obtain a signed application from the

parents of children who are already enrolled in Medicaid.

In its 5/17/2013 SHO Letter, CMS also outlined the following approaches for attaining signatures from

eligible parents:

a. States that are extending Medicaid eligibility to the new adult group can reactivate existing

applications for parents who recently applied for Medicaid and were denied. If a parent has

applied for Medicaid recently (for example, up to 90 days prior to the 2013 open enrollment

period), but has been denied because his or her income exceeded the Medicaid income limit

then in effect, the state may send a notice indicating the application has been reactivated. If

the parent’s income is below the level for which the state has declared it will use for Strategy 4,

the state could subsequently enroll the parent.

b. States can review children’s Medicaid cases to identify parents who have not applied for

themselves, but who are likely to be eligible based on having income below the level for which

the state has declared it will use for Strategy 4. The state can send such parents a notice

informing them that they now may be eligible for Medicaid and requesting any necessary

missing information. The state can then determine eligibility and enroll eligible parents.

What CMS requires

According to CMS’ 5/17/2013 State Health Official (SHO) Letter, in order to implement Strategy 4, a

state must request a waiver under section 1902(e)(14)(A) authority to allow the state to enroll parents

whose children are financially eligible for Medicaid at levels indicating likely parental eligibility, and

who meet other non-financial Medicaid requirements (such as citizenship documentation).

The state will also have to explain why such a procedure is necessary to help implement its eligibility

and enrollment system as well as meet its administrative responsibilities for the program. In

addition to this, the state will have to define the timeframe during which it will use this strategy.

Strategy 5 -- Adopting 12-month continuous eligibility for parents and other adults

Within current Medicaid regulations, states are allowed to provide 12 months of continuous eligibility

to children in their Medicaid and CHIP programs. This enables states to protect children by

guaranteeing that they are able to retain coverage for 12 months regardless of changes in family

circumstances such as household or income changes. It also allows states to provide children with a

secure source of health insurance and safeguards against interruptions to ongoing care. According to

CMS, as of January 2013, 32 states have adopted 12-month continuous eligibility in their Medicaid or

CHIP programs for children, with 23 states implementing the option in both programs

The 12-month continuous eligibility provision mitigates “churning”

Strategy 5 enables states to extend this continuous eligibility provision to parents and other adults.

As a result, this strategy allows states to protect adult Medicaid beneficiaries in the same way that

children are protected with this option. From a state’s operational perspective, this option also helps

to mitigate problems associated with the enrollment and re-enrollment of eligible people when they

lose coverage due to frequent changes in income. (This is also known as “churning.”)

Also, CMS notes that Strategy 5 allows states to better coordinate coverage for whole families,

especially in states that otherwise would have 12-month continuous eligibility only for children.

Otherwise, in these states, parents might have to renew their coverage more frequently than children.

What CMS requires

According to CMS’ 5/17/2013 State Health Official (SHO) Letter, in order to implement Strategy 5, a

state is required to acquire section 1115 demonstration authority. CMS requires states with existing

demonstrations to submit an amendment request along with a revised budget neutrality agreement

that includes the financial impact on the demonstration as a result of the amendment. States that do

not have existing section 1115 demonstrations would have to submit an application for a new

demonstration. New requests will need to conform to the section 1115 demonstration transparency

rules at 42 CFR 431.412(a).

As states work to meet their project goals and schedules associated with their initiatives to meet the

important tenants of the Affordable Care Act, CMS is serving as a willing partner to help states

improve their programs as well as deal with the pressures associating with implementing new

systems and processes. These strategies help states to provide additional pathways to enable eligible

individuals to gain access to Medicaid and achieve many of the key objectives of the ACA.

CAI is a global firm with a strong Public Sector practice focusing on assisting clients with their most

critical needs including Medicaid program changes and leveraging each of these 5 strategies.

CAI has been growing for over 27 years and today is comprised of more than 2,500 professionals. We

have offices throughout the United States, Canada, Europe, and the Asia-Pacific region, and industry

expertise in the Public Sector, Manufacturing, Insurance, Utilities, Hospitality, Logistics, Financial

Services, and Pharmaceuticals industries.

For more information about how CAI can help

you with your HHS needs please contact:

Joanne Gallagher

Director, Public Sector Practice

Joanne_Gallagher@compaid.com

Todd Schrubb

Director, Public Sector Practice

Todd_Schrubb@compaid.com