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An Introduction to Medicaid and CHIP Eligibility and Enrollment Performance Measures

BACKGROUND

The ACA makes key changes to Medicaid eligibility and enrollment. One key way the ACA seeks to reduce the number of uninsured is through an expansion of Medicaid eligibility to nearly all low income adults with incomes at or below 138% FPL. As enacted in the law, this expansion would occur nationwide, but the Supreme Court ruling on the ACA effectively made the expansion a state option. As of December 2013, 25 states and DC are moving forward with the expansion in 2014. The ACA also establishes new streamlined Medicaid eligibility and enrollment policies and a single application for Medicaid, CHIP, and subsidized Marketplace coverage.  All states must implement these simplifications, which are designed to connect people to coverage regardless of where or through what means a person applies for coverage, regardless of whether they implement the expansion.1 Performance data will be important for understanding the impact of these policies.

To implement the new eligibility and enrollment policies, most states needed to make major upgrades to their Medicaid eligibility and enrollment systems, providing an opportunity to improve data collection and reporting capacity. To support this work, CMS made available a substantially enhanced 90 percent federal matching rate for systems development. CMS also set a data reporting standard for the new systems to meet in order for states to qualify for the enhanced funding. Through a series of subsequent regulations and policy guidance, CMS indicated an intention to establish performance measures and, in August 2013, released 12 eligibility and enrollment performance indicators for states to begin reporting as of October (Box 1). However, by the time the indicators were released in August, many states had completed the bulk of their system builds, while others were still working with legacy systems, making it difficult for some states to accommodate the reporting requirements. Some states indicated that it will take time before they will be able to report the data as requested and that they will need to re-program their systems or manually extract data to do so.2

Box 1: CMS Guidance to Establish Medicaid and CHIP Eligibility and Enrollment Performance Data

April 2011: CMS established a 90 percent federal matching rate for state development of systems that support streamlined eligibility and enrollment processes and set data reporting and other standards for the systems to meet to qualify for the enhanced funding.3

March 2012: CMS issued interim final regulations to implement ACA eligibility policies, which described an intention to create eligibility and enrollment performance measures for states and broad parameters of such measures.

January 2013: CMS issued a request for information (RFI), proposing for public comment 17 indicators related to eligibility and enrollment and 14 indicators related to provider enrollment and payment.

August 2013: CMS issued a set of 12 Medicaid eligibility and enrollment performance indicators and provided definitions and specifications for each measure, which states began reporting in October.

December 2013: The first monthly report for a subset of the data was released.

KEY FINDINGS

Reporting of the new eligibility and enrollment performance indicators marks a significant improvement in timely and actionable data reporting for Medicaid and CHIP. States and the federal government have used performance data for many years for reporting, management, and evaluation, but reporting of timely and high-quality data has historically been inconsistent. Many states have been limited in their ability to utilize performance data because they have been relying on outdated or fragmented systems that do not provide for the collection and reporting of data.4 At the federal level, state-reported data are aggregated and used for national reporting on enrollment, spending, use of services, and quality. However, to date, there have been limitations in the timeliness, consistency, quality, and scope of these national data.5 Since 2009, CMS has undertaken cross-cutting efforts to improve the strength of Medicaid and CHIP data reporting and increase the use of these data in measuring program performance and informing decision-making.6 The new eligibility and enrollment performance indicators are the first major product of this effort and will provide some of timeliest data on Medicaid eligibility that have ever been reported.

Preliminary reported data suggest that enrollment in Medicaid and CHIP was off to a strong start since the beginning of open enrollment for the new Health Insurance Marketplaces. In December 2013, CMS reported on a subset of the performance indicators, focused on the number of applications received and the number of eligibility determinations made in October and November 2013 (Table 1). All 50 states and DC reported one or more of the measures, which is significant given the first-time nature of this data reporting. The data show that during October and November 2013:

  • More than 4.2 million applications were submitted directly to Medicaid and CHIP agencies. These reflect applications for states’ existing Medicaid and CHIP programs as well as for adults who became newly eligible for coverage in states that are implementing the Medicaid expansion effective January 2014.7 In addition, State-Based Marketplaces (SBMs) received some 549,373 applications for Medicaid, CHIP, or advance premium tax credits for Marketplace coverage.
  • Together, state Medicaid agencies and SBMs made nearly 3.9 million total new determinations for Medicaid and CHIP.  These reflect determinations for all Medicaid eligibility groups, not just for adults made newly eligible for Medicaid by the ACA’s Medicaid expansion. The bulk of the determinations were for Medicaid, reflecting the program’s broader size and scope.  The number of Medicaid and CHIP applications received and determinations made were lower in November than in October, which CMS attributed to the preliminary nature of the November data and fewer work days.
  • The data do not reflect Medicaid and CHIP applications initiated through the Federally-Facilitated Marketplace (FFM), which is determining or assessing Medicaid eligibility in 36 states. In separate data, HHS reported that as of the end of November 2013, the FFM and SBMs had determined or assessed just over 803,000 individuals as eligible for Medicaid or CHIP, with most (534,000) performed by SBMs.8 However, the Marketplace data aggregates Medicaid and CHIP determinations and assessments and it is not directly comparable to the determination data released by CMS. When CMS begins reporting the full set of performance indicators, they will provide more comprehensive information on Medicaid enrollment.

States are in varying stages of readiness to report the indicators, and data gaps and limitations constrain analysis of early data. Because states are continuing to develop their reporting capabilities, some were not able to report all of the indicators and some reported preliminary data. Moreover, the reported data are not consistent across states. For example, some states include data for CHIP or renewals in their application data, while others do not.  In addition, there are some issues that arise from how the data are reported. For example, some types of applications that were counted as submissions to Medicaid and CHIP agencies in the baseline data are counted as submissions to SBMs in October and November, and the number of submitted applications does not equal the number of individuals applying for coverage, because more than one person may be included on an application. Many of these limitations reflect the first-time nature of the data collection, challenges in collecting consistent data across states, and operational and reporting differences across different entities (Medicaid and the SBMs). These limitations restrict the ability to draw significant conclusions and to make cross-state comparisons. Reporting will improve over time as states and CMS gain experience and retool the systems with which they collect data.

Table 1: Medicaid and CHIP Applications and Determinations, October 1, 2013 – November 30, 2013
State Type of Marketplace* New Applications Submitted to Medicaid/CHIP Agencies Applications for Financial Assistance Submitted to SBM Total New Medicaid/CHIP Determinations
Total 4,209,742 549,373 3,926,068
Implementing Medicaid Expansion in 2014
Arizona FFM 298,066 N/A 108,676
Arkansas Partnership 117,511 N/A 140,759
California SBM 434,121 244,021 472,660
Colorado SBM 71,103 - 28,728
Connecticut SBM 51,426 10,996 41,325
Delaware Partnership 3,461 N/A 3,376
District of Columbia SBM 12,917 1,126 13,402
Hawaii SBM 15,260 - 7,791
Illinois Partnership 100,171 N/A 32,269
Iowa Partnership 40,341 N/A 21,341
Kentucky SBM 69,559 86,429 39,186
Maryland SBM 77,219 22,287 79,977
Massachusetts SBM 93,235 - -
Michigan Partnership 141,020 N/A 95,383
Minnesota SBM 76,985 - 33,046
Nevada SBM 20,983 - 10,630
New Jersey FFM 40,734 N/A 14,457
New Mexico Supported SBM 41,587 N/A 29,147
New York SBM - - 123,563
North Dakota FFM 4,541 N/A 5,152
Ohio FFM 319,886 N/A 80,036
Oregon SBM 17,539 11,865 99,272
Rhode Island SBM 11,565 - 5,297
Vermont SBM 32,224 13,463 119
Washington SBM - 159,186 159,186
West Virginia Partnership 46,488 N/A 90,302
Not Moving Forward with Medicaid Expansion in 2014
Alabama FFM 31,615 N/A 59,379
Alaska FFM 7,537 N/A 4,061
Florida FFM 560,950 N/A 303,594
Georgia FFM 197,562 N/A 153,252
Idaho Supported SBM 10,589 N/A 14,925
Indiana FFM 157,186 N/A 81,076
Kansas FFM 16,353 N/A 18,139
Louisiana FFM 53,027 N/A 39,003
Maine FFM 3,779 N/A 3,181
Mississippi FFM 66,876 N/A 46,468
Missouri FFM 84,556 N/A 48,740
Montana FFM 5,697 N/A 9,256
Nebraska FFM 15,847 N/A 16,217
New Hampshire Partnership 6,770 N/A 3,332
North Carolina FFM 132,118 N/A 107,476
Oklahoma FFM 67,542 N/A 44,898
Pennsylvania FFM 233,134 N/A 72,500
South Carolina FFM 57,621 N/A 139,335
South Dakota FFM 3,252 N/A 2,598
Tennessee FFM 7,065 N/A 3,338
Texas FFM 200,787 N/A 846,829
Utah FFM 45,245 N/A 142,175
Virginia FFM 58,633 N/A 26,822
Wisconsin FFM 40,144 N/A -
Wyoming FFM 7,915 N/A 4,394
Source:  CMS Medicaid and CHIP Monthly Applications and Eligibility Determinations Report, December 3, 2013 and December 20, 2013.
*In Partnership Marketplaces, states administer plan management functions, in-person consumer assistance functions, or both, and HHS performs the remaining functions.  In supported SBMs, states maintain plan management and consumer assistance functions and HHS operates enrollment systems. Seven states (KS, ME, MT, NE, OH, SD, and VA) conduct plan management activities to support the FFM.

CMS will update the performance indicators monthly and, over time, plans to report the full set of measures, which will offer a broader view of Medicaid and CHIP eligibility and enrollment performance. The initial data released in December are a subset of the full new set of 12 eligibility and enrollment performance indicators that CMS has asked states to report (Box 2)9. Appendix A provides a more detailed overview of the information each measure will provide and Appendix B provides measure definitions and reporting specifications. Together, the measures will provide insight into call center operations, overall demand for Medicaid and CHIP coverage, how applications are flowing through the system, Medicaid/CHIP agency workloads, the efficiency of eligibility and enrollment systems, and enrollment changes. This information can identify trends and potential areas of efficiency and inefficiency and will provide early information on the impact of the ACA’s new eligibility and enrollment policies.

Box 2:  Medicaid and CHIP Eligibility and Enrollment Performance

Indicators  Call Center Operations
1. Total Call Center Volume
2. Average Caller Wait Time
3. Rate of Abandoned Calls

Applications, Transfers, and Renewals
4. Total Number of Medicaid and CHIP Applications Received in Previous Week *
5. Total Number of Medicaid and CHIP Applications Received in Previous Month**
6. Total Number of Medicaid and CHIP Applications Received through Transfers from Marketplace
7. Total Number of Accounts up for Renewal

Determinations
8. Total Number of Individuals Determined Eligible for Medicaid or CHIP*
9. Total Number of Individuals Determined Ineligible for Medicaid or CHIP

Efficiency of Application Processing
10. Total Number of Applications and Redeterminations Pending a Determination
11. Processing Time for Eligibility Determinations

Enrollment
12. Total Enrollment

* Weekly application data has not been reported
** This measure was included in CMS’ December reports; the reports also included information on applications through SBMs.

As the quality and completeness of the performance data improve, they will provide more insight into program operations and allow for greater analysis both within and across states. The data’s greatest analytic value may be in measuring progress over time, identifying for example, changes in application volume or improved efficiency in application processing. As more consistent data are reported over a period of time, it will become possible to develop standards or benchmarks, which do not currently exist. However, when examining the data across states, it will still be important to recognize differences in state policies, operations, and demographics that may contribute to substantial variation in the performance measures.10  States have made different policy choices and have achieved varied progress to date in implementing the Medicaid eligibility and enrollment changes under the ACA, which challenge data interpretation.11

CONCLUSION

The new collection and reporting of eligibility and enrollment performance indicators are a significant step forward in the ability to use timely data to drive program improvement and assess performance in Medicaid and CHIP. With the new Marketplace enrollment metrics, the data will help provide an understanding of enrollment performance across coverage programs. Ultimately, states and the federal government will be able to employ these data as a management tool to guide decision-making, strengthen processes and inform policy changes and resource allocation. Over time, the measures can begin to provide insight into program performance by examining changes within a state, by examining measures across states or to develop national standards or goals. However, analysis of early performance data remains limited due to gaps and variations across states in reported data.

Looking forward, as the completeness, consistency, and quality of the data improve, it will allow for greater analysis and interpretation. Even then, the new performance measures alone will not provide a holistic assessment of whether Medicaid and CHIP are meeting ACA coverage goals. Fully assessing the impact of ACA will require broader outcome measures such as the reduction in the number of the uninsured, the rate at which eligible people enroll in coverage, and continuity of coverage for people over time. These measures generally are obtained through survey data and often can take years to establish.

This brief was prepared by Vikki Wachino, Cheryl Camillo, and Samuel Stromberg with NORC at the University of Chicago and Samantha Artiga and Robin Rudowitz with the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured.

Summary of Findings Appendices