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

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.

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.