Meeting the Expectations of the Affordable Care Act:

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1 Meeting the Expectations of the Affordable Care Act: Implications for Eligibility, Enrollment & Renewal in Pennsylvania s Medicaid and CHIP Programs Revised March 28, 2012 Community Legal Services, Inc kdama@clsphila.org Richard Weishaupt Kristen Dama Pennsylvania Health Law Project abacharach@phlp.org Ann Bacharach Laval Miller Wilson Rina Lieberman Summary The Patient Protection and Affordable Care Act 1 (ACA) establishes numerous requirements regarding eligibility and enrollment processes, with the goal of creating a streamlined system that will allow people to obtain health coverage that is most appropriate to their financial and health needs while maximizing reliance on electronic databases and other technology. The ACA offers an unprecedented opportunity to improve access to health care and health care services. Among many other reforms, the ACA requires a health insurance marketplace, known as an Exchange, to operate in each state. 2 The ACA gives each state the option of establishing and managing its own Exchange, operating an Exchange in partnership with HHS, or relying on HHS to implement and manage an Exchange within the state. 3 The law requires the new systems to enroll people with income under 400% of the federal poverty guidelines applying for health insurance affordability program into the correct program and to facilitate seamless transitions between programs when individuals and families circumstances change. The insurance affordability programs include Medicaid, CHIP, premium tax credits, costsharing reductions in the Exchange, and basic health plans, if available. This paper focuses on the revisions necessary to Pennsylvania s administration of Medicaid and CHIP under the ACA. New federal rules issued March 16, 2012 give states a new option: to allow the Exchange, rather than the Medicaid and CHIP agencies, to determine eligibility for Medicaid and CHIP. For the purposes of this paper, we describe the eligibility functions as those of the 1

2 Medicaid and CHIP agencies with the understanding that Pennsylvania may exercise its option to have the Exchange carry out the operations described. The Commonwealth must alter Medicaid and CHIP eligibility and renewal determinations in the next eighteen months to be ready for the first open enrollment period beginning October of Implementation of the new rules will require significant policy, process, and procedural changes to Pennsylvania s Medicaid and CHIP eligibility systems. These changes include reliance on datadriven electronic verification systems, acceptance of self attestation of information, real time eligibility determinations, prompt enrollment into coverage and annual renewal of coverage. They also include a single application for all insurance affordability programs, Medicaid, CHIP, and the Basic Health Program (where established) as well as Qualified Health Plans (QHPs) offered through the Exchanges. These changes will ease the burden on hundreds of thousands of Pennsylvanians now enrolled in Medicaid and CHIP, and those who will be newly eligible. Documentation of eligibility through paper proof, long a stumbling block for Pennsylvanians seeking public health insurance, will be replaced with electronic verification through connections to federal and state databases. These new operation requirements will also increase state administrative efficiencies while maintaining program integrity. The analysis in this paper is based on the text of the Patient Protection and Affordable Care Act, CHIPRA, final interim rules for the Exchange published March 13, 2012, final rules on Medicaid and CHIP Eligibility displayed March 16, 2012, federal guidance published in the Federal Register on July 15, 2011 and August 17, 2011, as well as on the Pennsylvania statutory and regulatory structure. Specific citations are contained in the endnotes. Background Title II (Role of Public Programs) of the ACA extends and simplifies Medicaid and CHIP eligibility in several ways: it standardizes income eligibility and it largely eliminates eligibility based on categories of age, household size, and health status. 5 More specifically, it expands eligibility using a new income methodology known as the Modified Adjusted Gross Income (MAGI) methodology. 6 MAGI relies on IRS tax rules and sets eligibility for Medicaid at 133% of the Federal Poverty Income Guidelines (FPIG), with an additional 5% across the board income disregard. 7 These income guidelines will eliminate Pennsylvania s current staircase of children s eligibility levels based on a child s age and will expand adult eligibility significantly, including eligibility for parents. 8 It further simplifies Medicaid eligibility rules by collapsing the number of categories of eligibility for children and families into four: parents/caretakers, children under 19, childless adults, and pregnant women. 9 2

3 Certain groups will be exempt from MAGI and will be eligible for Medicaid under the current eligibility rules. These groups include individuals who are: blind or have disabilities, over 65, in long term care, eligible based on non income factors such as receiving Supplemental Security Income (SSI), eligible for medically needy categories, and eligible for Medicare cost sharing. The federal rules do not require Pennsylvania to change its eligibility, enrollment, and renewal processes and procedures as they pertain to these groups, but the changes should extend to these groups as a matter of administrative efficiency and fairness. Beginning in 2014, these new program eligibility rules will expand Medicaid coverage to an additional 600,000 to 800,000 Pennsylvanians, with another two million people likely to buy coverage with and without subsidies and tax credits through the Exchange In October 2013, Exchanges must begin accepting applications for all coverage programs. 12 To be ready for the influx of new enrollees by that time, Pennsylvania s current Medicaid system will need to ensure its eligibility, enrollment and renewal policies, processes, and procedures are administered promptly and accurately. In March 2011, the federal Department of Health and Human Services (HHS) published final rules regarding enrollment and renewal for insurance affordability programs (Medicaid, CHIP, tax credits, and subsidies), as well as Qualified Health Plans (QHPs) and Exchange operations. 13 These rules will streamline enrollment and renewal processes for low income individuals and families and ease navigation for all. The rules establish commonsense guidelines for operating the Medicaid/CHIP/Exchange enrollment and renewal systems, including: Use of electronic data matches to the maximum extent possible to obtain information needed to provide real time eligibility determinations 14 and prompt enrollment into coverage programs; 15 Acceptance of self attestation for information other than immigration or citizenship status; 16 Single application for CHIP and Medicaid insurance affordability programs, and QHP s in the Exchange; and 17 Annual, simplified renewal. 18 Each of these new operating policies is described below in greater detail. Implemented properly, they will reduce administrative costs, decrease administrative errors, and increase the enrollment and retention of eligible individuals. To assure that Pennsylvania s Exchange operations will be fully functional and capable of accepting applications for Medicaid, CHIP, tax credits and subsidies as well as for Qualified Health Plans by October 2013, the Commonwealth must modernize its information technology infrastructure and current work flow for Medicaid and CHIP for all recipients. 3

4 Relying on Electronic Data for Real Time Eligibility Determinations and Prompt Enrollment The ACA requires a verification system that is data driven and relies on federal, state, and local electronic databases as the primary source of information, in contrast to the current system that relies on the consumer as the primary source of verification. Under the ACA, documentation may be requested from the consumer only if the Medicaid agency cannot find verification through these electronic sources. Further, the ACA permits both the Exchanges and Medicaid and CHIP to rely on self attestation for information other than immigration or citizenship status, unless the self attestation seems unreliable or inconsistent. 19 This shift from paper verification and the corresponding processing delays will allow for real time eligibility determinations and prompt enrollment. As the final rules on Medicaid and CHIP note, the purpose of these ACA changes to the Medicaid and CHIP programs is not only to benefit beneficiaries and enrollees, but also to reduce the administrative burden on States by simplifying and streamlining systems. 20 The ACA permits the HHS Secretary to modify the methods used under the program established by this section for the Exchange and verification of information if the Secretary determines such modifications would reduce the administrative costs and burdens on the applicant. 21 Pennsylvania should implement electronic verification immediately. In the current environment of overwhelmed and understaffed county assistance offices (CAOs) that struggle to process Medicaid applications and renewals in a timely manner, an immediate shift from paper verification to electronic verification would greatly improve caseworker efficiency and program integrity. Reliance on the existing connections to eleven electronic databases (e.g., Social Security, TALX, Unemployment Compensation, etc.) at the CAOs disposal decreases processing time for applications and redeterminations by eliminating the need to handle and scan paper documents. 22 This process of utilizing reliable information from third party sources is referred to as ex parte verification. Under Pennsylvania s Act 22 of 2011 and the Pennsylvania Welfare Code, caseworkers are required to use these databases to electronically double check a client s paper proof 23. Relying on electronic data rather than paper provided by the client as the primary source of verification eliminates this redundancy and inefficiency. Furthermore, it reduces inaccurate eligibility determinations due to data entry mistakes or other human error, and enhances Pennsylvania s efforts to combat waste, fraud, and abuse. To be ready for 2014, Pennsylvania must shift from paper verification for Medicaid and CHIP. Caseworkers and CHIP contractors must utilize reliable ex parte information from other income and means tested programs such as the Bureau of Child Support Enforcement, SNAP, and subsidized child care to confirm eligibility. The Commonwealth must also use its existing connections to databases (e.g., Social Security and TALX) as its primary source of income information, household demographics, citizenship, and immigration status. Only if appropriate 4

5 information cannot be found through electronic or other ex parte methods should caseworkers ask consumers for paper verification. While we expect that caseworkers will not be able to find information for a significant portion of the Medicaid and CHIP populations, a reduction of even 40% of the paper verification now currently processed through the CAOs would improve efficiency and program integrity. To further streamline CHIP and Medicaid eligibility determinations, Pennsylvania must consider other entities that collect reliable income information as further sources of dependable data. Self Attestation The final rules explicitly permit Medicaid and CHIP agencies as well as the Exchange to accept selfattestation (often referred to as self declaration) of income, and other eligibility information including proof of pregnancy from applicants and enrollees, excluding citizenship and immigration status from Medicaid and CHIP. 24 Self attestation has been used in Pennsylvania s Medicaid program for proof of pregnancy and, prior to the requirements of the Deficit Reduction Act, for citizenship status. The final rules, moreover, require states to exhaust electronic databases maintained by federal and state agencies to verify information provided by applicants and enrollees for Medicaid and CHIP before requesting additional information from individuals. 25 A state may ask individuals for further verification of household demographics, income or other information when the information obtained by the state from the third party data sources is not reasonably compatible with the attestation. 26 This new reasonable compatibility standard does not mean that information obtained through electronic data matching must be identical to information provided by the applicant. Rather, it means that information must be generally consistent and acceptance of self attestation by the Exchange or Medicaid and CHIP agencies or the Exchange may vary depending on circumstances. For example, self attestation may be sufficient when there is a discrepancy in information but that discrepancy does not change the eligibility outcome. To be ready for 2014, Pennsylvania must develop a method to obtain accurate self attestation. By designing forms and questions to correctly collect pertinent information from consumers, Pennsylvania can construct a system for self attestation that will obtain precise information and result in accurate eligibility determination and enrollment. Pennsylvania s Medicaid program currently allows presumptive eligibility for pregnant women based on self attestation of income and other eligibility criteria. Pennsylvania should build on the methods used for presumptive eligibility to develop and test expansion of self attestation for all applications and renewals for Medicaid and CHIP. Other states using self attestation for income can serve as models. For example, New Jersey and Ohio use self attestation as an element in their 5

6 presumptive eligibility process for enrolling eligible but uninsured children when they obtain health care at a designated presumptive eligibility site. A Single Application and Enrollment Process for All Health Insurance Programs The final rules require a single application for enrollment into Medicaid, CHIP, the insurance affordability programs, and non subsidized coverage provided through QHPs in the Exchange. 27 The HHS Secretary will develop the elements of a model application for use by state Exchanges. The ACA also permits states to develop and use alternative streamlined applications, subject to review and approval by the HHS Secretary. 28 Pennsylvania already does much of what will be required. Through a set of common data elements Pennsylvania s Medicaid and CHIP programs already share one application form and verification process at enrollment. While each CHIP application form and Medicaid s 600CH carries its own logo, the information gathered is consistent across all forms and limited to only the information necessary to determine eligibility. Through this interagency any form is a good form agreement and the automated Healthcare Handshake policies and procedures, applicants who are determined ineligible for either CHIP or Medicaid are automatically considered for the other program. 29 What is missing is a similar alignment for renewal. Medicaid requires semi annual reporting at six month intervals between annual redeterminations while CHIP has twelve month continuous eligibility. CHIP enrollees receive reminders to renew at 90, 60 and 30 days before coverage ends while Medicaid enrollees receive a renewal packet anywhere from 15 to 30 days before coverage ends. These aligned Medicaid/CHIP application processes and procedures form the basis for the required single application for the Exchange, and they serve as a model for further decisionmaking about alignment in processes and procedures through the Exchange. In the past, through regular communication and attention to outcomes, the Departments of Public Welfare and Insurance have worked collaboratively and consistently to address the complex intersection of the Medicaid and CHIP program rules for children. The challenge for 2013 and beyond will be to use the same forms, procedures, and methodology at renewal. Failing to unify renewal procedures makes the programs less efficient, leads to senseless and potentially harmful disenrollment and immediate re enrollment of children and adults who were continuously eligible, and wastes scarce government resources by requiring families to resubmit applications and verifications for their children. The ACA will require Pennsylvania to implement other joint efficiencies for application to the Medicaid and CHIP programs. For example, it requires each Exchange to create a web portal for information, application for and renewal of coverage, comparison shopping, cost calculations, 6

7 benefit explanations, and consumer assistance. 30 The Exchange must also allow consumers to obtain information and apply and renew coverage over the phone, through mail, and in person. 31 While the Exchanges will be primarily web based, these requirements address the range of communication technology available to consumers whose access to the Internet may be hampered by income, literacy, geography, and experience. The Commonwealth of Pennsylvania Application for Social Services (COMPASS) system, which serves as a web based application and renewal gateway for multiple Pennsylvania social service programs, forms a solid basis for a web based portal for the Exchange. To reach its full potential, COMPASS must allow applicants whose proof of income and other requirements cannot be electronically verified to submit the necessary proof electronically. DPW is piloting such capacity, but has been slow to implement this sensible reform. To be ready for 2014, Pennsylvania must unify the current renewal processes and procedures for Medicaid and CHIP. Current discrepancies that include six month reporting for Medicaid and twelve month continuous eligibility for CHIP, differing timelines for notifying CHIP and Medicaid recipients that renewal is due (90 days for CHIP; at most 30 days for Medicaid), telephonic renewal for CHIP but not for Medicaid, and administrative verification of income for CHIP but not for Medicaid must be addressed and aligned. By adopting the CHIP processes and procedures for Medicaid, Pennsylvania can improve the rate of retention for eligible children, increase program integrity, and avoid expensive and redundant disenrollment and subsequent re enrollment of eligible children. Moreover, aligning the renewal process will garner Medicaid bonus payments available through CHIPRA. Pennsylvania must review the COMPASS system for its fidelity to current rules for Medicaid and CHIP (one disparity is the requirement of an SSN for non applicants) as well as for low literacy appropriate format, logic, and language. Building on COMPASS, Pennsylvania must develop a single application/renewal process under the ACA that can be utilized online, as well in paper format. Further, Pennsylvania must develop ACA eligibility and enrollment systems that allow applications to be submitted online and through fax, mail, face to face interaction and over the phone. Through its Exchange planning process, Pennsylvania commissioned a review of the COMPASS infrastructure that determined it was a feasible platform for an Exchange portal. Pennsylvania should proceed to build the necessary additions and improvements to COMPASS, including the ability to accept non electronic verification, to establish a Pennsylvania Exchange portal. 32 Finally, there is a wealth of knowledge regarding outreach, enrollment, and renewal for children in the commonwealth. Pennsylvania should review the lessons learned in providing information and enrollment assistance through the Medicaid and CHIP programs. CHIP contractors have long provided outreach, enrollment and renewal assistance and the commonwealth has funded community based organizations to provide customized assistance to specific underserved 7

8 populations. In addition, CMS has awarded outreach and enrollment grants to three communitybased organizations in Pennsylvania. Through these and other entities, Pennsylvania should craft a navigator program that meets the needs of individuals and families who will approach the Exchange for coverage. Annual Simplified Renewal The final regulations require annual redetermination of eligibility for Medicaid, 33 CHIP, 34 and the Exchange programs. 35 The renewal process required by the final regulations should be more efficient, less cumbersome, and faster compared to current Medicaid renewal process. This is a profound shift from the current practice in Medicaid that requires six month review for the majority of recipients. At the same time, the process will maintain existing rules that ensure program integrity. For example, enrollees in Medicaid and CHIP programs will be required to report significant changes in income within 30 days of the changes regardless of the renewal dates or processes. 36 For Medicaid renewals, the final regulations require Medicaid agencies to evaluate eligibility by first looking to reliable information contained in the individual s account or other more current information available to the agency, including but not limited to information accessed through any data bases. 37 If this information is sufficient to confirm continued eligibility, coverage will be renewed automatically and states will send appropriate notice of this decision to enrollees without requiring additional action. 38 Only where agencies cannot confirm continued eligibility with the information available to them will they send enrollees a pre populated renewal form containing the information that is necessary for renewal currently available to the agency, such as income and demographic information, with a request for updated or corrected information from the enrollee. The enrollees will then have a reasonable period of at least 30 days to return the form and furnish any necessary updated information either in person, online, via telephone, or by mail. 39 The final rules further state that, for enrollees who do not return the signed form, the Medicaid and CHIP agencies must determine continuing eligibility using the information prepopulated in the form. 40 HHS final rules on renewal will not apply to individuals enrolled in Medicaid under non MAGI rules (see above discussion in background). However, it will be administratively costly and confusing to state workers and consumers to create a two tiered process for renewal. Pennsylvania is one of only two states that require six month reporting for children and one of only five states that require six month reporting for adults. Maintaining semi annual redetermination or reporting requirements for some Medicaid recipients undermines the promise of the ACA by contributing to churn in states like Pennsylvania, where state Medicaid agencies struggle to process redetermination and accompanying paperwork promptly, leading to unnecessary termination of or suspension of benefits for eligible recipients. 8

9 No policy reason justifies placing a greater administrative burden on traditional Medicaid recipients. It would be fundamentally unfair even discriminatory to streamline significantly the redetermination process for some Medicaid recipients but not for others, particularly because most traditional Medicaid recipients will be poorer and sicker than expanded Medicaid recipients. To be ready for 2014: With the eleven databases cited above including the TALX and New Hire employment systems as well as Social Security Administration data now connected to the Department of Public Welfare, Pennsylvania should begin administrative renewal. For those clients whose income is unlikely to change or whose income is well within the limits and not likely to impact eligibility for Medicaid, ex parte renewal could be undertaken by both Medicaid and CHIP. DPW caseworkers are using these databases to verify paper proof and could easily reverse their process to use electronic proof as their primary verification and rely on paper proof obtained from the family as a secondary verification process, if necessary. The Department of Insurance is already pilot testing this concept for CHIP renewals. Pennsylvania should add the most recent income available to the caseworker to the current prepopulated demographic fields and ask clients to affirm the information or make corrections, sign the form and return it. No further proof would be required unless the client made corrections to the form. In addition, Pennsylvania should test telephonic affirmation of the information populated on the form as well as telephonic signature. Finally, Pennsylvania must eliminate the six month redetermination required for Medicaid. This will require amending Public Welfare Code 62 P.S Funding One of the most difficult challenges in turning the ACA s mandates into an on the ground reality is the cost. Pennsylvania s Medicaid program, like other states, is experiencing severe budgetary stress. However, there is an unprecedented opportunity for federal support to develop the modernized systems needed to meet the ACA s requirements for a fully accessible Medicaid program. Pennsylvania has already including significant funding for the necessary information technology improvements in its Level One Exchange Planning Grant. Other federal funding opportunities include Medicaid matching funds and CHIPRA bonus payments for increased enrollment of eligible children in Medicaid. Medicaid Matching Funds Pennsylvania can draw down federal funds that will match 90% of the costs of improving the current legacy computerized system. In April of 2011, the federal department of health and 9

10 human services released guidance that allows states to draw down 90:10 matching funds to make improvements to the Medicaid Management Information Systems (MMIS). Specifically, section 1903(a)(3)(A)(i) of the Social Security Act provides that Federal financial participation (FFP) is available at 90 percent of expenditures for the design, development, or installation of mechanized claims processing and information retrieval systems as the Secretary determines are likely to provide more efficient, economical and effective administration of the plan and to be compatible with the claims processing and information retrieval systems utilized in the administration of title XVIII [Medicare]. 42 This 90/10 matching rate for the overhaul or enhancement of mechanized data and claims processing and information retrieval systems in accordance with Medicaid Information Technology Architecture (MITA) requires prior approval and is available through December of Investing now in the design, development, and installation of new and improved information technology will bring Pennsylvania closer to supporting accurate and timely processing of eligibility decisions and effective communications with providers, beneficiaries, and the public. Improvements will also produce the required transaction data, reports, and performance information for program evaluation, assessment, accountability, and transparency. These enhancements will also allow inter operability between Medicaid, CHIP, and the Exchange, ensuring seamless coordination. They will also support coordination and sharing of information among health information technology platforms, as well as public health agencies, human services programs and community organizations providing outreach enrollment assistance services. CHIPRA Bonus Payments In reauthorizing the CHIP in 2009, Congress created a financial incentive for states to simplify pathways to enroll uninsured, low income children into public health programs. 43 By simplifying these enrollment and renewal procedures, practices the ACA requires states to have in place by 2014, Pennsylvania can draw down these payments. Last year and the year before, Pennsylvania lost out on millions of dollars in federal funding; funding that could provide health care to children in Medicaid and CHIP. According to the Lewin Group s Medicaid Bonus Payment Calculator 44, Pennsylvania has left more than $145 million on the table since Other states received millions for their children s health programs: Wisconsin received $23 million, Alabama received $54.9 million, and New Jersey received $8.7 million. In reauthorizing the Children s Health Insurance Program, Congress created an incentive for states to enroll the lowest income children; those who qualify for Medicaid. By increasing the number of children enrolled in Medicaid and simplifying enrollment and renewal practices, states can draw 10

11 down federal bonus payments in two tiers. Tier 1 (increasing enrollment beyond the baseline of 2007 enrollment by 4%) brings a bonus of 15% of the cost of Medicaid services. Tier 2 (increasing enrollment by 10%) brings a bonus of 62.5% of the cost of Medicaid services. Pennsylvania has reached the Tier 2 threshold, increasing enrollment by more than 93,000 children since the baseline year of To garner the bonus payments, Pennsylvania also has to implement five of eight enrollment and renewal simplification strategies. These strategies rely on system changes that will be required for implementation of the ACA and will make the eligibility systems easier for families to navigate now and at the same time improve the integrity of the programs. To qualify for the bonus payments, the simplification strategies must be in place for at least six months of the FFY with the intent to remain in place beyond that period. The eight strategies listed in the CHIPRA legislation: Continuous 12 month eligibility; No assets test for children or if there is an assets test, state workers will verify rather than require families to produce verification; No requirement for a face to face interview; A joint application for Medicaid and CHIP; Administrative or automatic renewal; Presumptive eligibility; Express lane eligibility (i.e., using a means tested program such as Free School Lunch to authorize eligibility for Medicaid without additional information from the family); and Premium assistance With the exception of premium assistance, each strategy must be implemented in both Medicaid and CHIP. Premium assistance can be implemented in either Medicaid or CHIP. Pennsylvania currently utilizes two of the options: no assets test for children; and no requirement for a face to face interview. With minor adjustments, Pennsylvania could implement administrative renewal, a joint application and verification process, Express Lane eligibility and premium assistance. More work would be needed to implement the remaining options of 12 month continuous eligibility, and presumptive eligibility. States that have implemented these simplifications have not only garnered significant bonus payments but have also seen increased enrollment and decreased administrative costs. Neighboring states, New Jersey, Ohio, and Maryland, have implemented a number of the CHIPRA simplification strategies that dovetail nicely with the ACA requirements while reducing the amount of paperwork to be processed and staff time needed to confirm or deny eligibility at application and renewal. Louisiana saved $8 to $12 million annually through that state s implementation of these administrative strategies

12 Electronic verification, as required by the ACA, is the centerpiece for many of these simplification strategies. Electronic verification and the requirements for renewal under the ACA exactly mirror the requirements for administrative renewal. Relying on electronic verification to confirm eligibility will allow Pennsylvania to implement presumptive eligibility for children at sites designated by the state. New Jersey and other states have designated health care delivery sites such as hospital emergency rooms and federally qualified health centers as presumptive eligibility providers. Penalties for Medicaid Non Compliance Under current Medicaid law, the Secretary of HHS has the discretion to withhold the federal share of Medicaid funds if a state is deemed non compliant. The Secretary may withhold the entire federal share or the portion of the federal share related to the area of non compliance. In 2014, the federal share for the Medicaid expansion population will be 100% of the costs for the newly eligible to the state. The federal share for those eligible under current rules is 54% of the costs. Failure to meet the requirements, therefore, could result in severe penalty to the commonwealth. Pennsylvania must work intently and efficiently now to meet the compliance standards for 2014 and beyond. Conclusion With a quickly approaching 2013 deadline for ACA implementation, Pennsylvania must begin working in partnership with federal agencies and stakeholders to put critical policies and systems in place. There is much to be done to develop, test, and put into operation eligibility and enrollment systems for Medicaid, CHIP, the insurance affordability programs, and the Exchange by October of Federal funds through 90:10 administrative Medicaid matching dollars are available. We support Pennsylvania s application for these funds. Part of the Exchange Level One grant Pennsylvania recently received has been designated for the development of the necessary IT infrastructure. We further encourage Pennsylvania to seek out additional funds in the form of CHIPRA bonus payments. Pennsylvania s Medicaid and CHIP programs will significantly benefit from modernized application, enrollment and renewal systems, processes and procedures. 12

13 Additional Resources KAISER COMM N ON MEDICAID & THE UNINSURED, THE HENRY J. KAISER FAMILY FOUND., PUB. NO. 8254, MEDICAID ELIGIBILITY, ENROLLMENT SIMPLIFICATION, AND COORDINATION UNDER THE AFFORDABLE CARE ACT: A SUMMARY OF CMS S AUGUST 17, 2011 PROPOSED RULES AND KEY ISSUES TO CONSIDER (2011), available at DEP T OF HEALTH & HUMAN SERVS., CONNECTING KIDS TO COVERAGE: STEADY GROWTH, NEW INNOVATION 2011: CHIPRA ANNUAL REPORT (2012), available at MARTHA HEBERLEIN ET AL., GEORGETOWN UNIV. CTR. FOR CHILDREN & FAMILIES & KAISER COMM N ON MEDICAID & THE UNINSURED, PUB. NO. 8130, PERFORMING UNDER PRESSURE: ANNUAL FINDINGS OF A 50 STATE SURVEY OF ELIGIBILITY, ENROLLMENT, RENEWAL AND COST SHARING POLICIES IN MEDICAID AND CHIP, (2012), available at DEBORAH BACHRACH & KINDA SERAFI, MANATT HEALTH SOLUTIONS, FEDERAL REQUIREMENTS AND STATE FLEXIBILITIES FOR VERIFYING ELIGIBILITY CRITERIA (Feb. 2012), available at requirements and state flexibilities forverifying eligibility criteria/. MANATT HEALTH SOLUTIONS, OVERVIEW AND ANALYSIS OF PROPOSED EXCHANGE, MEDICAID AND IRS REGULATIONS ISSUED ON AUGUST 12, 2011 (State Health Reform Assistance Network Issue Brief Sept. 2011), available at STAN DORN, IAN HILL & FIONA ADAMS, URBAN INST., LOUISIANA BREAKS NEW GROUND: THE NATION'S FIRST USE OF AUTOMATIC ENROLLMENT THROUGH EXPRESS LANE ELIGIBILITY (2012), available at Endnotes 1 Patient Protection and Affordable Care Act, Pub. L. No , 124 Stat. 119 (2010), amended by Health Care and Education Reconciliation Act of 2010, Pub. L. No , 124 Stat (2010). 2 See, e.g., id. at 1311(b) & 1321(c). 3 See Establishment of Exchanges and Qualified Health Plans, 77 Fed. Reg. 18,310, 18,446 (March 27, 2012) (to be codified at 45 C.F.R ). 4 See Establishment of Exchanges and Qualified Health Plans, 77 Fed. Reg. 18,310, 18,446 (March 27, 2012) (to be codified at 45 C.F.R ). 13

14 5 Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. 17,144, 17,145 (Mar. 23, 2012) (to be codified at 42 C.F.R. pts. 431, 435, 437). 6 Id. at 17, Id. at 17,206 (to be codified at 42 C.F.R ). 8 Current Medicaid eligibility for children is 185% of FPIG for pregnant women and infants up to age 1, 133% for children age 1 up to age 6, 100% for children age 6 up to age 19. Income deductions are allowed for transportation to and from work, child care expenses, and a certain percentage of earned income. 9 Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17, JOHN HOLAHAN & IRENE HEADEN, URBAN INST. & KAISER COMM N ON MEDICAID & THE UNINSURED, MEDICAID COVERAGE AND SPENDING IN HEALTH REFORM: NATIONAL AND STATE-BY-STATE RESULTS FOR ADULTS AT OR UNDER 133% FPL (2010). 11 KPMG, COMMONWEALTH OF PENNSYLVANIA, PENNSYLVANIA DEPARTMENT OF INSURANCE: INSURANCE EXCHANGE PLANNING (2011). 12 See Establishment of Exchanges and Qualified Health Plans, 77 Fed. Reg. at 18,462 (to be codified at 45 C.F.R ). 13 See Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. 17,144 (Mar. 23, 2012) (to be codified at 42 C.F.R. pts. 431, 435, 437); Establishment of Exchanges and Qualified Health Plans, 77 Fed. Reg. 18,310 (March 27, 2012) (to be codified at 45 C.F.R. pts. 155, 156, 157). 14 Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17, (to be codified at 42 C.F.R ). 15 Id. at 17,212 (to be codified at 42 C.F.R ). 16 Id. (to be codified at 42 C.F.R ). 17 Id. at 17,208 (to be codified at 42 C.F.R ). 18 Id. at 17,210, 17,215 (to be codified at 42 C.F.R , ). 19 Id. at 17, Id. at 17, Id. at 17,211 (to be codified at 42 C.F.R (k)). 22 Data sources include the Social Security Administration, the Department of Homeland Security, and the IRS as well as state data sources to verify current income information such as TALX and the New Hire databases. In addition, under Medicaid and CHIP, other programs that collect income and demographic information (SNAP, the Bureau of Child Support Enforcement (BCSE), subsidized child care programs) can also be utilized for verification. 23 Public Welfare Code Omnibus Amendments, P.L. 89, No. 22 (Oct. 22, 2010), available at 24 Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17,212 (to be codified at 42 C.F.R ). 25 Id. (to be codified at 42 C.F.R ). 26 Id. (to be codified at 42 C.F.R (c)). 27 Id. at 17,208 (to be codified at 42 C.F.R ). 28 Id. (to be codified at 42 C.F.R (a)(2)). 29 PA. CHILDREN S HEALTH INS. PROGRAM, POLICY AND PROCEDURES MANUAL (2008); Memorandum from Joanne Glover, Director, Bureau of Operations, Health Care Handshake: Automated Process for Handling Applications for Health Care Benefits (October 6, 2008), available at 30 Establishment of Exchanges and Qualified Health Plans, 77 Fed. Reg. 18,310, 18,448 (Mar. 27, 2012) (to be codified at 42 C.F.R (b)). 31 Id. at 18,462 (to be codified at 42 C.F.R (c)(2)). 32 KPMG, supra note Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17,210 (to be codified at 42 C.F.R ). 34 Id. at 17,215 (to be codified at 42 C.F.R ). 35 Establishment of Exchanges and Qualified Health Plans, 77 Fed. Reg. at 18, (to be codified at 42 C.F.R ). 36 Id. at 18,459 (to be codified at 42 C.F.R (b)). 37 Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17,210 (to be codified at 42 C.F.R (a)(2)). 38 Id. (to be codified at 42 C.F.R (a)(2)(i)-(ii)). 39 Id. (to be codified at 42 C.F.R (a)(3)(i)). 40 Id PA. CODE (2008); 55 PA. CODE (2002). 42 Federal Funding for Medicaid Eligibility Determination and Enrollment Activities, 76 Fed. Reg. 21,950 (Apr. 19, 2011) (to be codified at 42 C.F.R. pt. 433). 14

15 43 The Lewin Group s Medicaid Bonus Payment Calculator estimates Pennsylvania left at least $113 million dollars on the table for Federal Fiscal year 2010 and $61 million for Federal Fiscal year An estimated $122 million might be available for FFY Medicaid Bonus Payment Calculator, LEWIN GROUP, (last visited Mar. 20, 2012). 45 Children s Health Insurance Program Reauthorization Act of 2009, Pub. L. No , sec. 104, 2105(a)(3)-(4), 123 Stat. 8, (to be codified at 42 U.S.C. 1397ee(a)(3)-(4)). 46 Letter from Cindy Mann, Director, Ctr. for Medicaid & State Operations (Dec. 15, 2009), available at 47 STAN DORN, IAN HILL & FIONA ADAMS, URBAN INST., LOUISIANA BREAKS NEW GROUND: THE NATION'S FIRST USE OF AUTOMATIC ENROLLMENT THROUGH EXPRESS LANE ELIGIBILITY (2012), available at 15