An Introduction to Medicaid and CHIP Eligibility and Enrollment Performance Measures
S. Artiga and R. Rudowitz, “The Many Roads to Medicaid: An Overview of How People are Connecting to the Program Today,” Kaiser Commission on Medicaid and the Uninsured (December 2013).
National Association of Medicaid Directors, “NAMD ACA Snapshot –Open Enrollment, Week 3;” (October 21, 2013); “NAMD ACA Snapshot—Open Enrollment, Week 4,” (October 28, 2013) “NAMD ACA Snapshot – Open Enrollment, Week 5” (November 4, 2013); “NAMD Open Enrollment Snapshot –Open Enrollment, Week 7” (November 25, 2013); “NAMD ACA Snapshot – Open Enrollment, Week 10” (December 16, 2013) http://medicaiddirectors.org/.
These systems would otherwise have been matched at the 50 percent Medicaid administrative matching rate. CMS is matching the costs of developing and building systems at 90 percent; the cost of operating the systems will be matched at 75 percent.
“Performance Measurement Under Health Reform, Proposed Measures for Eligibility and Enrollment Systems and Key Issues and Trade-offs to Consider, Kaiser Commission on Medicaid and the Uninsured, (December 2011); "C. Trenholm et al.,“Using Data to Drive State Improvement in Enrollment and Retention Performance,” Maximizing Enrollment for Robert Wood Johnson Foundation (November 2011). .
P. Thompson, “CMS Initiatives to Improve Data for Medicaid Program Operations and Evaluation,” presentation to the Medicaid and CHIP Payment and Access Commission (October 28-29, 2010), available at: https://docs.google.com/viewer?pid=sites&srcid=bWFjcGFjLmdvdnxtYWNwYWN8Z3g6NDlmNTk3YzJlYzZkZDAzMg
P. Thompson presentation.
23 states were implementing the Medicaid expansion at the start of October 2013. Ohio and Michigan are also implementing the expansion, but had not yet begin processing applications for newly eligible adults as of October.
ASPE Issue Brief, “Health Insurance Marketplace: December Enrollment Report For the Period: October 1-November 30,” December 11,2013’ ASPE Issue Brief, “Health Insurance Marketplace: November Enrollment Report,” November 13,2013.
CMS notes that data released for the first three months of open enrollment through the Marketplace (October 2013-December 2013) will remain focused on applications and eligibility determinations. The agency anticipates reporting on additional indicators, including total enrollment, after Medicaid coverage for newly eligible individuals begins in January 2014.
National Association of Medicaid Directors, “NAMD Open Enrollment Snapshot –Open Enrollment, Week 7” (November 25, 2013) http://medicaiddirectors.org/.
M. Heberlein et al., “Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive.” Kaiser Commission on Medicaid and the Uninsured (November 2013).
Because of the definition of ‘call center’ used by CMS, data from different states may not be comparable. The measures may be subject to overcount, as helplines may receive calls about other benefits such as TANF and SNAP. Conversely, a state may experience undercount, due to calls about Medicaid that are directed to a FFM exchange or if a call center is excluded from the report because it lacks the capability to report on call volume.
This data will not inform observations about the accuracy of eligibility determinations. CMS is developing approaches to measuring the accuracy of determinations of eligibility and ineligibility that align with Affordable Care Act eligibility rules. Guidance in letter to states from D. Taylor and C. Mann, Centers for Medicare and Medicaid Services, “ Payment Error Rate Measurement (PERM) eligibility reviews, Medicaid Eligibility Quality Control (MEQC) Program, and development of an interim approach for assessing payment error for eligibility,” SHO 13-005 (August 2013), available at: http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-005.pdf
CMS is not as part of this measurement effort collecting disenrollment and denial reason codes, which would provide data that CMS and states could use to identify, for example, whether individuals are denied because of an increase in income, a move out of state, or because they were missing information or verification. M. Harrington, C. Trenholm, A. Snyder, “New Denial and Disenrollment Coding Strategies to Drive State Enrollment Performance,” Maximizing Enrollment Issue Brief, published by the Robert Wood Johnson Foundation and National Academy for State Health Policy (October 2012).
Table published online, “Targeted Enrollment Strategies.” Centers for Medicare and Medicaid Services (October 2013), available at: http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Targeted-Enrollment-Strategies/targeted-enrollment-strategies.html
CMS has long set timeframes for the time required to make eligibility determinations of 45 days for most Medicaid populations and 90 days for beneficiaries whose eligibility is based on being disabled. CMS has recently reiterated those outer limits, but also stated an expectation that eligibility determinations can be carried out significantly more quickly, and in most cases in “real time,” due to simplified rules and improved technology. Center for Medicaid and CHIP Services, “Request for Information: Performance Indicators for Medicaid and Children’s Health Insurance Program Business Functions: Solicitation of Public Input” and final regulation 77 CFR 17144, “Eligibility Changes under the Affordable Care Act of 2010,” (March 23, 2012).