Medicaid programs under the gun to get "No Wrong Door" up and running

While some Medicaid programs have taken steps to streamline the enrollment process in recent years, the "No Wrong Door" system required by health care reform is a very different challenge. This means that a person can file a single application to find out if he or she is eligible not just for Medicaid, but also the Children's Health Insurance Program (CHIP), the "exchange" portals that will be set up so that individuals can more easily obtain health insurance and a variety of other programs.

"This is a hot topic, and is becoming even more critical as states think through the Medicaid, CHIP, and exchange linkages," says Kip Piper, MA, FACHE, president of the Health Results Group in Washington, DC.

States will first need to consider their current eligibility and enrollment systems to determine how much work has to be done. "The first thing on their plate is looking at their systems," says Robin Rudowitz, a principal policy analyst for the Kaiser Commission on Medicaid and the Uninsured in Washington, DC. "The new requirements don't hit until 2014, but it takes a long time to procure new eligibility systems or modify systems."

Most states don't have health information exchanges (HIEs), or anything similar, in operation currently. "So, they will need to develop those and figure out how enrollment systems are going to work," says Ms. Rudowitz. "You can't wait until 2014 to find out that the system isn't there to accommodate new applications."

Access to data is needed

According to John G. Folkemer, deputy secretary of health care financing at Maryland's Department of Health and Mental Hygiene, "the big challenge is coming up with a system that does everything it has to do."

"The system has to be able to accommodate a person applying by phone, in person, by fax, and over the Internet — any way at all," says Mr. Folkemer. Maryland's system needs to be much more automated, he explains, so the person applying can very quickly be sent in the right direction, whether to Medicaid, CHIP, or the HIE.

"That is really the biggest challenge that we have," says Mr. Folkemer. "We need to build a system and get it in place by 2013, so the government can approve it and we're all ready to go for 2014."

Maryland's three multiagency "No Wrong Door" workgroup subcommittees are focusing on effective education and outreach, integration of services and resources, and technology. The groups will make recommendations by the end of 2010.

Several years ago, Maryland eliminated the asset test for its CHIP program and did the same for adults after expanding coverage for parents in 2008. "We keep looking at the enrollment form and the eligibility process, trying to figure out any ways we can simplify it and make it easier," says Mr. Folkemer.

Recently, the department started working with the state controller's office to obtain data on families with children who might be eligible for Medicaid or CHIP, or parents who might be eligible for the new expanded coverage.

"We have spaces on income tax forms now, where somebody can indicate whether they have health insurance or not and whether their children do or not; they can indicate whether they are interested in getting information," says Mr. Folkemer. "We are moving more in that direction, to tie [eligibility determination] to income tax and the controller's office."

Mr. Folkemer anticipates that health reform's requirement for a common eligibility form for Medicaid, CHIP, and the HIE will be a "major, major change. We're going to have to develop a new system to be able to handle that and smoothly get the information on income tax and citizenship from the federal government."

Mr. Folkemer is hoping that the Centers for Medicare & Medicaid Services (CMS) will quickly come up with a simplified process to give states access to this data.

"In the future, we'll be relying on the IRS to provide the same kind of information that the state controller's office is now providing," says Mr. Folkemer. "At this point, I just don't know to what extent [the current process] can be incorporated into the new system."

Groundwork being laid

"No Wrong Door" eligibility systems "could be the kiosks of tomorrow," says Roger Gantz, policy director for Washington Medicaid. "But what adds to the complexity is the fact that an exchange can be both a portal, and as we read it, actually do Medicaid eligibility."

The question is how the Medicaid and HIE eligibility processes can be integrated. "It is a good question. We are going to have to wrestle with that and figure out how to build on the efforts of today," says Mr. Gantz.

Washington Medicaid has been working to simplify eligibility for several years. "A work group has been in the works well before health reform passed," says Mr. Gantz. "The single portal concept is relatively new, though."

While there is a 90% federal match for Medicaid Management Information Systems (MMIS), this is not the case for eligibility systems. "Unless they are literally part of the MMIS, eligibility systems do not enjoy those match rates. We have a big ACES [Automated Client Eligibility System] system that literally does the eligibility for Medicaid and feeds our MMIS system, but we don't enjoy those match rates," says Mr. Gantz.

This means that these goals will need to be accomplished under the standard 50% match rates, at a time when the Washington Medicaid program faces major reductions. Whatever money is spent on a new information system could mean further reductions in medical coverage.

The state is trying to come up with a way to use its MAGI [Modified Adjusted Gross Income] system to simplify eligibility further. "While we have not had any formal conversations with CMS, we've been involved with the waiver process," says Mr. Gantz. "I think they would be interested in states doing some demonstration work in that area."

The current system determines eligibility for Medicaid, CHIP, and Apple Health for Kids, which covers children up to 300% of Federal Poverty Level. "Our state has been one of the few national leaders that says children are children. We have provided coverage for children whose immigration status would make them ineligible for Medicaid," says Mr. Gantz.

That record may be threatened by current budget cuts, though. The program for immigrant children, which is entirely state-funded, has been placed on the cut list for legislative consideration over the next session.

The application process can be completed online with an electronic signature, with no asset requirements. "The one thing we have not done is Express Lane Eligibility. We think it would bring on some 8,000 children that look like they would be eligible for Apple Health, but are not," says Mr. Gantz. "We have a decision package that would test that out. Unfortunately, it's coming at a time when we could conceivably reduce coverage for other programs."

Preventing eligibility loss

An annual review process helps to reduce turnover rates, but there is still disenrollment because of non-completion of applications. "That does ultimately rest with the families," says Mr. Gantz. "You would assume that the families that lost coverage would come back eventually, but over half of them do not."

The idea of "passive eligibility" was considered, where a family would remain eligible unless the department heard otherwise. "That is one of the questions that we wrestle with. But based on the analysis we did, we can't do that," says Mr. Gantz. "More than half don't come back on, and we're paying a premium to a health plan. That's not prudent either."

Instead, calls are made to remind families of upcoming renewal dates and to offer help if needed. This outreach work, done by community-based organizations, is expected to help lay the groundwork for health care reform. "We can build on the work that they have done with low-income populations. That will extend into the exchange," says Mr. Gantz.

A system is needed to ensure that someone doesn't lose eligibility just because he or she fails to complete an application. "But having said that, my assumption is that there will be at least an annual renewal process for coverage in the exchange. What happens if somebody doesn't complete the renewal process?" asks Mr. Gantz.

The assumption may be made that these individuals are now low-income and need to be on Medicaid. "If so, then Medicaid will need information, because we don't know where they are," says Mr. Gantz.

Mr. Gantz adds that he believes the mechanisms already in place to sustain eligibility for low-income families will prove useful for outreach for the Medicaid expansion population in 2014.

"We will bring on 400,000 new people in the Medicaid program eventually, so we've got more people to look at," says Mr. Gantz. "Childless adults will bring on a new set of challenges, but at least we have an infrastructure to build from."

Contact Mr. Folkemer at (410) 767-4139 or FolkemerJ@dhmh.state.md.us, Mr. Gantz at (360) 725-1880 or gantzrp@dshs.wa.gov, Mr. Piper at (202) 558-5658 or piper@healthresultsgroup.com, and Ms. Rudowitz at (202) 347-5270 or RobinR@kff.org.