Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
M   S A
OST  TATES  NTICIPATED 
 
I   S
MPLEMENTING  TREAMLINED 
 
E
  LIGIBILITY AND 
 
E 2014 
  NROLLMENT BY 
 
 
Stuart Wright 
Deputy Inspector General for 
Evaluation and Inspections 
 
February 2013 
OEI-07-10-00530   
   
EXECUTIVE SUMMARY:  MOST STATES ANTICIPATE IMPLEMENTING 
STREAMLINED ELIGIBILITY AND ENROLLMENT BY 2014 
OEI-07-10-00530 
 
 
WHY WE DID THIS STUDY  
 
The Patient Protection and Affordable Care Act (ACA) requires the Secretary of Health 
and Human Services and States to streamline procedures for determining eligibility and 
enrolling applicants in State health subsidy programs (i.e., Medicaid, the Childrens 
Health Insurance Program (CHIP), and State exchanges) by January 1, 2014.  
Specifically, section 1413 of the ACA requires changes to (1) eligibility and enrollment 
systems, (2) application forms, and (3) eligibility data sharing among State health subsidy 
programs.  Given the complexity of the required changes, an assessment of States 
readiness to implement the streamlined systems by the target date can provide useful 
information to the Centers for Medicare & Medicaid Services (CMS) and to States. 
 
HOW WE DID THIS STUDY 
 
In March and April 2012, we conducted a survey regarding States readiness to 
implement streamlined eligibility and enrollment systems.  We asked all 50 States and the 
District of Columbia (States) questions about (1) eligibility and enrollment systems, 
(2) application forms, and (3) eligibility data sharing.  We also asked States about 
guidance they had received on how to achieve streamlined eligibility and enrollment 
requirements, and about how helpful it was.   
 
WHAT WE FOUND 
 
Of the 45 States that responded to the survey, 35 reported that they anticipate 
implementing streamlined eligibility and enrollment systems, streamlined application 
forms, and data sharing and matching by January 1, 2014.  However, States reported 
challenges, such as implementing the requirements by the target date and upgrading 
outdated eligibility and enrollment systems.  They described various funding issues 
related to implementing needed changes.  States also reported needing information and 
guidance, particularly on the Secretarys application form, the planned Federal data 
services hub, and the calculation of Modified Adjusted Gross Income.   
 
WHAT WE CONCLUDE
 
Although States generally anticipate implementing streamlined eligibility and enrollment 
by the target date, they reported needing information and guidance on a number of topics.  
CMS should continue to provide guidance to States as they prepare to implement the 
streamlined eligibility and enrollment systems.  In its comments, CMS described its 
ongoing work with States to implement open enrollment for Medicaid, CHIP, and State 
exchanges since our survey responses were collected.   
   
   
 
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................5 
Findings........................................................................................................7 
Thirty-five States reported that they anticipate implementing  
all streamlined eligibility and enrollment requirements by  
January 1, 2014 ................................................................................7 
States reported challenges and areas where further Federal  
guidance is needed ...........................................................................9 
Conclusion .................................................................................................12 
Agency Comments and Office of Inspector General Response .....12 
Appendixes ................................................................................................13 
A:  Number of States Responding to Selected Survey  
Questions........................................................................................13 
B:  State-Reported Challenges To Implementing Streamlined  
Eligibility and Enrollment Requirements ......................................14 
C:  Agency Comments ...................................................................16 
Acknowledgments......................................................................................22 
 
   
   
OBJECTIVES 
Based on State survey results as of March and April 2012, to determine the extent 
to which: 
1.  States anticipate implementing the streamlined eligibility and enrollment 
requirements of the Patient Protection and Affordable Care Act (ACA) by 
January 1, 2014; and 
2.  the Centers for Medicare & Medicaid Services (CMS) guidance has helped 
States implement these requirements. 
BACKGROUND  
The ACA1 increases access to health insurance by expanding existing programs 
and establishing new ones.  The ACA authorizes States to expand eligibility for 
Medicaid to higher income individuals.  An estimated 11 million additional 
beneficiaries will enroll in Medicaid and the Childrens Health Insurance Program 
(CHIP) by 2022 because of these changes.2  The ACA also requires the 
establishment of new State health benefit exchanges (State exchanges) in each 
State3an estimated 26 million people will enroll in the State exchanges by 
2022.4  In this report, we will refer to Medicaid, CHIP, and the State exchanges 
collectively as State health subsidy programs.5 
Given the anticipated increases in enrollment for State health subsidy programs, 
the ACA also requires the establishment of streamlined eligibility and enrollment 
procedures that can accommodate a large volume of applicants and enroll 
applicants into the correct program.   
 
1 ACA (P.L. 111-148, enacted on March 23, 2010) was amended by the Health Care and 
Education Reconciliation Act of 2010 (P.L. 111-152, enacted on March 30, 2010).  Together, 
these laws are referred to as the Affordable Care Act. 
2 Congressional Budget Office (CBO), Estimates for the Insurance Coverage Provisions of the 
Affordable Care Act Updated for the Recent Supreme Court Decision, July 2012, p. 13.  Accessed 
at http://www.cbo.gov/ on July 30, 2012. 
3 ACA  1311(b).  The purpose of State exchanges is to establish a mechanism to help individuals 
and businesses find and purchase affordable health insurance.  Under the ACA, States may 
establish their own exchanges or, if they choose not to, the Department of Health and Human 
Services (HHS) will operate exchanges for them.  ACA  1321(c).  States can also elect to 
establish a partnership exchange, in which HHS and the State work together to operate different 
functions of the exchange.  77 Fed. Reg. 18310, 18325 (Mar. 27, 2010). 
4 CBO, Health Insurance Exchanges: CBOs March 2012 Baseline, March 13, 2012.  Accessed at 
http://www.cbo.gov/ on January 25, 2013. 
5 ACA  1413(e). 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  1 
   
   
Streamlined Eligibility and Enrollment Requirements 
Section 1413 of the ACA requires the Secretary of Health and Human Services 
(the Secretary) and the States to take certain actions related to streamlining 
application and enrollment procedures.  Under section 1413, the Secretary must 
establish a system that would enable residents in each State to apply for and enroll 
in any of that States health subsidy programs.  The Secretary must develop a 
single, streamlined application form that all States may adopt and use.6  Each 
State must develop a secure electronic interface for exchange of information 
among programs, and each State program must participate in data-matching 
agreements for obtaining eligibility information from various sources.  In 
addition, section 2201 of the ACA requires State Medicaid and CHIP agencies to 
undertake certain coordination and simplification activities and to participate in 
and comply with the requirements for the system the Secretary establishes.  The 
target date for State Medicaid participation in the streamlined system is January 1, 
2014.7  Section 1321 of the ACA also establishes January 1, 2014, as the target 
date for States that decide to operate exchanges to meet standards the Secretary 
sets, including eligibility and enrollment streamlining.8   
Eligibility and Enrollment Systems.  The Secretary must establish a system in 
which residents of each State can apply for enrollment, receive a determination of 
eligibility, and participate in applicable State health subsidy programs.9  This 
system should automatically enroll individuals who apply for any State health 
subsidy program in the correct program.  For example, if an individual applies for 
Medicaid, but is found ineligible, the system should automatically determine 
whether he or she meets the eligibility requirements for CHIP (or another State 
health subsidy program).  If the system determines that the individual is eligible 
for CHIP, it should enroll him or her in that program without requiring an 
additional application. 
Application Forms.  Section 1413 of the ACA directs the Secretary to develop and 
provide to all States a single streamlined form that may be used to apply for 
coverage through Medicaid, CHIP, and the exchanges.10  The form must be: 
  used to apply for enrollment in all State health subsidy programs; 
  filed online, in person, by mail, by telephone, or by facsimile; 
 
6 CMS plans to release the final version of the Secretarys application form in 2013. 
7 ACA  2201 adds  1943 to the Social Security Act to require that a State implement enrollment 
simplification and coordination among Medicaid, CHIP, and the State exchanges;  1943(b)(3) in 
particular requires State Medicaid and CHIP agencies to participate in and comply with the 
requirements for systems established under ACA  1413. 
8 ACA  1321(b). 
9 ACA  1413(a). 
10 ACA  1413(b). 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  2 
   
   
  filed with any of a States health subsidy programs; and 
  completed easily by applicants.11 
A State may use the application form that the Secretary is developing or develop 
its own form consistent with standards promulgated by the Secretary.  On January 
28, 2013, CMS released materials related to the Secretarys form, including a list 
of questions and the business logic that will be contained in the online application, 
a paper version of the form, and videos depicting the application process.  These 
materials were available for public comment through February 28, 2013. 
Eligibility Data Sharing.  Section 1413 establishes an eligibility data-sharing 
requirement with three parts.  The first part requires that each State develop a 
secure electronic interface that allows sharing of eligibility data among all of its 
health subsidy programs to coordinate and verify information regarding an 
applicants eligibility.12  Each States secure electronic interface must allow a 
determination of eligibility for all the State health subsidy programs based on the 
information provided on the application form.  The second part requires that, to 
the maximum extent practicable, each State health subsidy program establish, 
verify, and update eligibility using data-matching arrangements with other 
agencies within the State and determine applicant eligibility on the basis of 
reliable third-party data (e.g., wage, employment, and income databases; 13 State 
vital records information; and Express Lane agencies14).  The third part requires 
that States establish data-sharing agreements with SSA, IRS, and the Department 
of Homeland Security (DHS).15  
In Guidance for Exchange and Medicaid Information Technology (IT) Systems 
Version 2.0, released in May 2011, CMS describes its plans for a Federal data 
services hub to assist States with verifying citizenship, immigration, and tax 
information with SSA, IRS, and DHS.  CMS plans for the hub to support the 
delivery of information to State health subsidy programs. 
 
11 ACA  1413(b).  In a proposed Medicaid and CHIP rule, CMS indicated that it would address 
the readability and accessibility of applications, forms, and other communications in future 
guidance.  76 Fed. Reg. 51161 (Aug. 17, 2011).  As of July 2012, CMS had not published a final 
rule regarding the readability and accessibility of applications, forms, and other communications. 
12 ACA  1413(c). 
13 These databases could include State unemployment compensation agencies databases, Social 
Security Administration (SSA) and Internal Revenue Service (IRS) databases, and National 
Directory of New Hires databases. 
14 An Express Lane agency is defined by section 1902(e)(13)(F)(i) of the Social Security Act as a 
public agency that (I) is determined by the State Medicaid agency or the State CHIP agency (as 
applicable) to be capable of making the determinations of one or more eligibility requirements....  
Express Lane agencies vary by State, but often include Women, Infants, and Children Program 
agencies; Supplemental Nutrition Assistance Program agencies; Temporary Assistance for Needy 
Families agencies; and other public assistance agencies. 
15 ACA  1413(c); 76 Fed. Reg. 51164 (Aug. 17, 2011). 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  3 
   
   
Guidance to States 
CMS has released numerous guidance documents related to streamlined eligibility 
and enrollment systems, including letters to State officials, informational 
bulletins, grant announcements, proposed and final rules, IT guidance and 
supplements, and question-and-answer documents.  Additionally, CMS has hosted 
conference calls, Webinars, and a national conference on eligibility and 
enrollment.16  At the conclusion of our analysis, the guidance documents released 
included among others:   
  Guidance for Exchange and Medicaid Information Technology (IT) 
Systems Version 1.0describing how information technology systems 
should support and enable business operations and processes for health 
care coverage through State exchanges and Medicaid.17 
  Guidance for Exchange and Medicaid Information Technology (IT) 
Systems Version 2.0establishing a framework and approach for 
developing IT systems.18   
  Medicaid Program; Eligibility Changes Under the Affordable Care Act of 
2010publishing final rules regarding Medicaid and CHIP eligibility and 
enrollment requirements under the ACA.19   
  Supporting Statement for Data Collection to Support Eligibility 
Determinations for Insurance Affordability Programs and Enrollment 
through Affordable Insurance Exchanges, Medicaid and Childrens Health 
Insurance Program Agenciespresenting information on the data 
elements planned for inclusion in the Secretarys single streamlined 
application form.20 
Funding for Streamlined Eligibility and Enrollment Systems 
Enhanced Federal Medicaid Matching Funds for Eligibility and Enrollment 
System Upgrades.  CMS amended its regulations to make enhanced Federal 
financial participation available to State Medicaid programs for activities related 
 
16 CMS hosted a national conference on Medicaid and CHIP eligibility and enrollment in 
September 2011, entitled On the Road to 2014: Medicaid and Children's Health Insurance 
Program (CHIP) Eligibility and Enrollment. 
17 CMS, Guidance for Exchange and Medicaid Information Technology (IT) Systems Version 1.0, 
November 3, 2010.  Accessed at https://www.cms.gov/ on August 31, 2011. 
18 CMS, Guidance for Exchange and Medicaid Information Technology (IT) Systems Version 2.0, 
May 2011.  Accessed at http://www.medicaid.gov on July 11, 2012. 
19 77 Fed. Reg. 17143 (Mar. 23, 2012). 
20 CMS, Supporting Statement for Data Collection to Support Eligibility Determinations for 
Insurance Affordability Programs and Enrollment through Affordable Insurance Exchanges, 
Medicaid and Childrens Health Insurance Program Agencies; Appendix A:  Data Elements for 
Application to Support Eligibility Determinations for Enrollment through Affordable Insurance 
Exchanges, Medicaid and Childrens Health Insurance Program Agencies, July 9, 2012.  
Accessed at http://www.medicaid.gov on July 11, 2012. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  4 
   
   
to eligibility determination systems.21  Under the amended regulations, approved 
States will receive a Federal matching rate of 90 percent of a States costs for 
design, development, installation, or enhancement of eligibility and enrollment 
systems until December 31, 2015.  States will receive 75-percent matching 
Federal funds to assist in operating such systems.22 
State Planning and Establishment Grants.  State Planning and Establishment 
grants are available to all 50 States and the District of Columbia (States) for 
planning and establishing State exchanges.23  States may use these funds in a 
variety of ways, including to assess current information technology systems; 
determine the statutory and administrative changes needed to build exchanges; 
and coordinate streamlined eligibility and enrollment systems across State health 
programs, including Medicaid and CHIP. 
METHODOLOGY 
We conducted an online survey in March and April 2012 to assess States 
readiness to implement streamlined eligibility and enrollment requirements.  We 
asked the States to respond to the survey, which was structured around the three 
main requirements of section 1413:  (1) development of an eligibility and 
enrollment system, (2) application forms, and (3) eligibility data sharing.  We also 
asked States about the guidance they had received on streamlined eligibility and 
enrollment requirements and about how helpful it was. 
Data Collection and Analysis 
Identification of Contacts.  We requested from CMS a list of contacts 
knowledgeable about the States efforts to implement streamlined eligibility and 
enrollment.  In response, CMS provided contact information for each State 
Medicaid Director.  We sent a letter to each State Medicaid Director requesting 
that a contact person knowledgeable about the States efforts to implement 
streamlined eligibility and enrollment respond to our survey.  In some cases, the 
contact people identified by the State Medicaid Directors were not employed by 
the State Medicaid agencies.  For example, some States have set up offices 
specifically to coordinate implementation of ACA-related initiatives; in each of 
those States, we were referred to a contact person in that office.  We created a 
database of the designated contacts, including names, telephone numbers, and 
email addresses. 
 
21 76 Fed. Reg. 21950 (Apr. 19, 2011). 
22 Ibid. 
23 Office of Consumer Information and Insurance Oversight, State Planning and Establishment 
Grants for the Affordable Care Acts Exchanges, Funding Opportunity Number:  IE-HBE-10-001, 
July 29, 2010.  In September 2010, CMS announced that it had awarded State Planning and 
Establishment grants to 48 States and the District of Columbia.  Alaska and Minnesota did not 
apply for the grant. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  5 
   
   
Data Collection and Response Rate.  We sent an email asking the designated 
contact for each State to respond to the online survey.  If a contact did not respond 
to the email, we sent a followup email asking for a response.  If a contact did not 
respond to the followup email, we contacted him or her again by telephone and 
email.  After 1 month of followup, we had not received survey responses from six 
States, which we considered to be nonresponders:  Connecticut, Louisiana, 
Massachusetts, Missouri, Utah,24 and Wisconsin.25  We received responses from 
45 States, for a response rate of 88 percent.  However, the 45 responding States 
did not necessarily answer every question.  At least 39 States responded to every 
question that required a response.   
Online Survey and Analysis of Responses.  The online survey focused on actions 
that States have taken or are planning to take to implement streamlined eligibility 
and enrollment.  Additionally, the survey inquired as to whether each State 
anticipated implementing streamlined eligibility and enrollment procedures by 
January 1, 2014, the target date for State Medicaid programs and exchanges to 
conform to requirements for the Secretarys streamlined system.26  Finally, the 
survey asked States about the guidance they had received from CMS and about 
whether they found it helpful.   
Limitations 
The data presented in our findings reflect States responses to our survey; we did 
not verify responses.   
Survey responses were received from March 8 to April 30, 2012.  CMS has since 
issued additional program and policy guidance on State options for structuring 
and implementing exchanges and eligibility systems.  States may have responded 
differently had they completed our survey after CMS issued guidance on these 
matters.   
Our findings reflect States assessments, as of MarchApril 2012, of their own 
readiness to implement streamlined eligibility and enrollment procedures. 
Standards 
This study was conducted in accordance with the Quality Standards for Inspection 
and Evaluation issued by the Council of the Inspectors General on Integrity and 
Efficiency. 
 
24 State officials stated that because Utah implemented many reforms to its State health care 
programs before the ACA was enacted, they were unable to respond to our survey questions as 
they were worded. 
25 These six States represented less than 5 percent of national Medicaid enrollment at the end of 
2010.  Kaiser Commission on Medicaid and the Uninsured, Monthly Medicaid Enrollment (in 
thousands), December 2010.  Accessed at www.statehealthfacts.org on August 21, 2012. 
26 Under ACA  2201, State Medicaid and CHIP programs must participate in and comply with 
HHS  requirements for a streamlined enrollment system by January 1, 2014.  Under ACA  1321, 
States electing to operate exchanges would have to take certain initial steps by January 1, 2014.  
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  6 
   
   
FINDINGS 
Thirty-five States reported that they anticipate implementing 
all streamlined eligibility and enrollment requirements by 
January 1, 2014 
Of the 45 States that responded to the online survey, 35 reported that they 
anticipate implementing all of the following:  streamlined eligibility and 
enrollment systems, streamlined application forms, and data sharing and 
matching.27  Table 1 provides an overview of States responses related to each of 
the requirements. 
Table 1:  State Responses Regarding Streamlined Eligibility and Enrollment Requirements 
Type of Requirement  Yes  No  No Response 
All Requirements 
States that anticipate implementing streamlined eligibility and 
enrollment systems, streamlined application forms, and data sharing  35  9  7 
and matching by January 1, 2014 
Eligibility and Enrollment Systems 
States that anticipate having systems that meet requirements related 
38  5  8 
to eligibility and enrollment systems by January 1, 2014 
Application Forms 
States that anticipate having application forms that meet requirements 
40  2  9 
by January 1, 2014 
Data Sharing and Matching 
States that anticipate implementing all eligibility data sharing 
37  5  9 
and matching requirements 
States that anticipate having secure electronic interfaces that meet 
37  5  9 
requirements by January 1, 2014 
States that anticipate having data sharing and matching agreements 
40  2  9 
that meet requirements by January 1, 2014 
Source:  Office of Inspector General (OIG) analysis of State survey responses, 2012. 
In April 2012, 38 States anticipated having eligibility and enrollment 
systems that meet requirements  
Five States did not anticipate having systems that can determine eligibility for and 
enroll applicants in applicable State health subsidy programs by January 1, 2014.  
These States are Florida, Idaho, Nebraska, New Hampshire, and Oklahoma.  
When asked for further information, three of these States explained why they did 
not anticipate having such systems.28  Nebraska explained that it would take 
2 to 4 years to implement a system that would meet all of the requirements.  New 
 
27 See Appendix A for the number of States responding to each survey question.  
28 The other two States did not explain why they did not anticipate having systems that met the 
requirements by the target date. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  7 
   
   
Hampshire explained that it was having difficulty obtaining funding to make the 
necessary system changes.  Oklahoma explained that the States Medicaid 
eligibility system was being enhanced where possible; however, staff were not 
certain that the system would meet the requirements by that time.   
In April 2012, 40 States anticipated having application forms that 
meet the streamlined eligibility and enrollment requirements  
States may create their own streamlined application forms consistent with 
standards promulgated by the Secretary or adopt the application form that the 
Secretary is developing.  In April 2012, 40 States anticipated having forms that 
would satisfy the Secretarys requirements by January 1, 2014.  Thirty of these 
forty States were unsure whether they would develop State-specific forms or use 
the form the Secretary is developing.  Of the remaining 10 States, 6 will use the 
form the Secretary is developing and 4 will create their own.  Finally, two States 
explained that they did not have enough information to determine whether they 
would have compliant forms. 
In April 2012, 37 States anticipated implementing all three eligibility 
data-sharing requirements  
In April 2012, 37 States anticipated implementing all three eligibility data-sharing 
requirements by January 1, 2014; varying numbers of States anticipated 
implementing individual requirements.29  Thirty-two States indicated that, by 
January 1, 2014, their planned electronic interfaces will allow determinations of 
eligibility for all of their health subsidy programs based on the information 
provided on the single application form.  Seven States indicated that their planned 
electronic interfaces will not allow determinations of eligibility for all State health 
subsidy programs based on the single application form.  These States explained 
that they did not have enough information to state with certainty what their 
planned electronic interfaces would be capable of by January 1, 2014.30 
The ACA requires States to share data among all of their health subsidy programs 
to determine Medicaid eligibility and to match data with SSA, IRS, and DHS.  
Forty States anticipated having data sharing and matching agreements that meet 
the streamlined eligibility and enrollment requirements by January 1, 2014.  
Thirty-four States indicated that they currently have data-sharing agreements with 
at least one other agency within the State; however, the agencies with which these 
agreements existed differed among States (see Table 2). 
 
29 See Table 1, Data Sharing and Matching. 
30 One of these seven States did not comment specifically on this question but, in other responses, 
indicated that difficulties with gaining access to funding were impeding its progress with planning 
and implementing all the streamlined eligibility and enrollment requirements and making State 
staff uncertain whether they could meet the January 1, 2014, target date. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  8 
   
   
Table 2:  States Data-Sharing Agreements With Other State Agencies  
Number of States With Data-Sharing 
Agency 
Agreements 
Temporary Assistance for Needy Families  28 
Vital Records Department  27 
Supplemental Nutrition Assistance 
27 
Program 
Source:  OIG analysis of State online survey responses, 2012. 
Thirty-one States indicated that they currently have data-matching agreements 
with at least one of the required Federal agencies (see Table 3). 
Table 3:  States Data-Matching Agreements With Federal Agencies 
Number of States With 
Agency  Data-Matching 
Agreements 
SSA  31 
IRS  20 
DHS  13 
Source:  OIG analysis of State online survey responses, 2012. 
States reported challenges and areas where further Federal 
guidance is needed 
Although States generally indicated that they will meet streamlined eligibility and 
enrollment requirements by January 1, 2014, they also reported encountering 
challenges.  These included the difficulty of meeting the implementation target 
date, outdated eligibility and enrollment systems, and lack of funds to implement 
streamlined eligibility and enrollment systems.  States found CMS guidance on 
streamlined eligibility and enrollment helpful.  However, they reported needing 
further guidance on a number of subjects, including the Secretarys application 
form and the planned Federal data hub. 
States reported three main challenges to implementing streamlined 
eligibility and enrollment systems 
These challenges were the difficulty of meeting the target date, outdated 
eligibility and enrollment systems, and lack of funds to implement streamlined 
eligibility and enrollment systems. 
Implementing the ACA requirements by January 1, 2014, was the challenge that 
States most frequently reported.  Twenty-six States indicated that implementing 
systems that meet streamlined eligibility and enrollment requirements by that date 
would be difficult because of the complexity of the systems required.   
Eleven States reported that having outdated eligibility and enrollment systems 
was a challenge.  These States described their existing eligibility systems as being 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  9 
   
   
decades old and lacking the functionality needed to implement streamlined 
eligibility requirements.  One State summed up both of these challenges, stating, 
Without a prior online system, we are having to create something from scratch.  
Creating both the policy and technical capacity in such a short timeframe, with 
inadequate Federal guidance, is the biggest hurdle. 
The third commonly reported challenge was lack of funds and delay in receiving 
Federal funds.  States also reported that slow authorization processes for State 
funds approval were challenging.  For instance, one State reported that 
[D]iscussions are still occurring in the [State] legislature and we do not yet have 
spending authority for our ... grant.31  This State received its State Planning and 
Establishment grant award from CMS on September 30, 2010, and responded to 
our survey in March 2012.  Thus, a year and a half had elapsed while the State 
was unable to spend its grant funds because of the continuing discussions in its 
legislature.  States reported other challenges as well; see Appendix B for a 
complete list. 
In April 2012, States reported finding CMS guidance helpful; 
however, they needed further guidance on a number of subjects 
In April 2012, 38 States reported finding the CMS guidance they had received 
helpful as they prepared to implement the streamlined eligibility and enrollment 
systems.  However, many States indicated that they need further guidance on 
various subjects.  As previously noted, CMS has released additional guidance 
since the completion of our survey; this guidance may have fulfilled States 
reported needs.   
Sixteen States reported needing further information about the format and 
appearance of the Secretarys application form.  One State said, It is difficult to 
answer ... questions, let alone plan on [sic] as the secretary-developed form has 
not yet been released to States.  CMS released draft application materials for 
public comment in January 2013, and plans to release the final version of the 
Secretarys application form later in 2013. 
Fourteen States reported needing more information about the planned Federal data 
services hub.  States reported needing to know how they will access the planned 
hub and what information will be available through it.  As one State expressed, 
Until we have clear guidance from CMS on the Federal data hub and what 
 
31 This State was referencing its State Planning and Establishment grant.  These grant funds were 
for a variety of purposes related to planning and establishing State exchanges, including 
coordinating streamlined eligibility and enrollment systems across State health subsidy programs.  
Office of Consumer Information and Insurance Oversight, State Planning and Establishment 
Grants for the Affordable Care Acts Exchanges, Funding Opportunity Number:  IE-HBE-10-001, 
July 29, 2010.   
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  10 
   
   
information will be available through the hub, it is difficult to determine what 
other [data sharing agreements] need to be established. 
Ten States reported needing additional and more specific guidance on the 
Modified Adjusted Gross Income (MAGI) requirements, particularly on MAGI 
conversion, determining household composition, and calculating income (see 
Table 4).32   
Table 4:  Subjects on Which States Reported Needing Further Guidance* 
Subject   Number of States 
Format and appearance of the Secretarys application form  16 
How to use the Federal data services hub   14 
MAGI final rules, income standards, calculation methodology  10 
Interface between State exchange and Federal hub  9 
Data elements available through the Federal data services hub and required on 
7 
the Secretarys application form 
Eligibility and enrollment systems for Federal and partnership exchanges**  5 
How to determine and claim Federal Medical Assistance Percentage correctly  4 
Standards for making real-time eligibility decisions  3 
Data matching with IRS  3 
Federal exchanges for States that have chosen not to run State exchanges  2 
Coordinating various application requirements and processing timeframes among 
1 
State health subsidy programs 
National Information Exchange Model   1 
Reasonable compatibility between self-attested information and data sources  1 
Source:  OIG analysis of State online survey responses, 2012. 
* These subjects are also listed in Appendix A because States described the lack of guidance on these subjects as 
challenges to implementation of streamlined eligibility and enrollment. 
** In a partnership exchange, the State and HHS work together to operate the exchange. 
 Federal Medical Assistance Percentages are used to determine the Federal matching funds rates for certain State 
medical and social service programs, including Medicaid. 
  The National Information Exchange Model is a seamless, standards-based, interoperable model for data exchange 
among government agencies. 
 
 
   
 
32 The ACA requires the simplification of financial eligibility by using MAGI, a single standard to 
determine eligibility for most Medicaid and CHIP enrollees.  In the March 2012 final rules on 
changes to Medicaid and CHIP eligibility, CMS gives definitions and methodologies related to 
calculating MAGI.  77 Fed. Reg. 17143 (Mar. 23, 2012).  See also National Medicare Training 
Program, Module 12:  Medicaid & the Childrens Health Insurance Program (CHIP).  Accessed 
at https://www.cms.gov on June 29, 2012. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  11 
   
   
CONCLUSION  
Of the 45 States that responded to the online survey, 35 reported that they 
anticipate implementing all of the following by January 1, 2014:  streamlined 
eligibility and enrollment systems, streamlined application forms, and data 
sharing and matching.  However, we collected the responses before additional 
CMS program and policy guidance was issued, including guidance on any 
implications of the Supreme Courts decision regarding Medicaid program 
requirements.  States responses may have been different had they completed the 
survey after this information became available.  States reported significant 
challenges with issues such as implementing the requirements by the target date, 
upgrading outdated eligibility and enrollment systems, and obtaining funding to 
implement needed changes.  States reported needing information and guidance, 
particularly on the Secretarys application form, the planned Federal data services 
hub, and MAGI.  We conclude that CMS should continue to provide guidance to 
States as they prepare to implement streamlined eligibility and enrollment 
systems. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its comments, CMS described steps that it has taken, since we collected our 
survey responses, to help States implement open enrollment for Medicaid, CHIP, 
and State exchanges.  CMS described actions it has taken in each of the following 
areas:  eligibility and enrollment systems development, streamlined application 
form development, the Federal data services hub, State operations and technical 
assistance and operational tools, and exchange grants and federally facilitated 
exchange development.  We recognize CMSs commitment to guiding and 
assisting States in implementing streamlined eligibility and enrollment systems.   
   
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  12 
   
   
APPENDIX A 
We asked all 50 States and the District of Columbia (States) to respond to an 
online survey.  The 45 States that responded did not always answer every 
question.  The table below shows the number of States responding to each 
question.  The questions have been paraphrased for the sake of brevity. 
Number of States Responding to Selected Survey Questions 
Survey Question  Responding  Not Responding 
All Requirements 
States that anticipate implementing all three types of streamlined eligibility and 
44  7 
enrollment requirements by January 1, 2014* 
Eligibility and Enrollment Systems 
Do you anticipate having a system that meets all requirements of section 1413 
43  8 
related to eligibility and enrollment systems by January 1, 2014? 
Application Forms 
Do you anticipate having an application form that meets the requirements of 
42  9 
section 1413 by January 1, 2014? 
Have you decided whether you will develop a State-specific application form 
40  11 
or use the Secretarys application form? 
Will you develop a State-specific application form or use the Secretarys 
10  0 
application form?** 
Data Sharing and Matching 
States that anticipate implementing all eligibility data sharing and matching 
42  9 
requirements* 
Do you anticipate having a secure electronic interface that meets the 
42  9 
requirements of section 1413 by January 1, 2014? 
Do you anticipate having data sharing and matching agreements that meet 
42  9 
the requirements of section 1413 by January 1, 2014? 
Will your planned electronic interface allow determinations of eligibility for all 
of the States health subsidy programs based on the information provided on  39  12 
the single application form? 
With which other agencies within the State do you currently have data-sharing 
40  11 
agreements? 
With which Federal agencies do you currently have data-sharing agreements?  41  10 
Challenges 
States that reported encountering challenges in implementing the streamlined 
45  6  
eligibility and enrollment requirements* 
Guidance 
Have you found the guidance available to date regarding implementation of 
43  10 
streamlined eligibility and enrollment requirements helpful? 
States that reported needing additional guidance to progress toward 
implementation of the streamlined eligibility and enrollment requirements in  45  6  
section 1413* 
*These rows represent the total responses to multiple questions in the online survey. 
**Only the States that had decided whether to develop State-specific applications or to use the Secretarys form were asked this question. 
Source:  Office of Inspector General analysis of State survey responses, 2012. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  13 
   
   
APPENDIX B 
We asked all 50 States and the District of Columbia (States) to respond to an 
online survey.  Responding States reported numerous challenges in implementing 
streamlined eligibility and enrollment requirements, including the need for 
guidance and information on a number of subjects.  A categorized list of the 
reported challenges follows. 
State-Reported Challenges To Implementing Streamlined Eligibility and Enrollment Requirements 
Number of 
Challenge 
States Reporting 
Eligibility and Enrollment Systems/Technical Issues    
   Difficulty of improving outdated systems to implement requirements  11 
Need for standards for making real-time eligibility decisions  3 
 
Shortage of vendors to build new systems  2 
 
   Insufficient Internet/network bandwidth to implement system upgrades  1 
Complexity of Requirements    
   Difficulty of collecting needed information in a simple streamlined form  10 
Difficulty of interfacing between State exchange and Federal hub  9 
 
Difficulty of requesting information to determine eligibility for different populations and programs (e.g., Modified 
   5 
Adjusted Gross Income (MAGI) and non-MAGI) 
   Coordinating varying application requirements and processing timeframes among State programs  1 
Effects on State Operations    
Influx of enrollees   9 
 
   Need for extensive staff training on new eligibility and enrollment system  6 
   Greater State assistance needed for applicants who cannot apply online    3 
Changing mindset/culture of State staff from paper-based application process to online application and 
   2 
enrollment 
Reduction of available jobs for State/county workers because of increased efficiency of improved eligibility 
   1 
system 
Data Needs    
Need for information on data elements available through the Federal data services hub and required on the 
   7 
Secretarys application form 
   Need for information on data that will be available through Internal Revenue Service data matching  1 
   Renegotiating data-sharing agreements  1 
Guidance    
Insufficient guidance overall  27 
 
Format and appearance of the Secretarys application form  16 
 
   How to use the Federal data services hub   14 
   MAGI final rules, income standards, calculation methodology  10 
   Need for information on eligibility and enrollment systems for Federal and hybrid exchanges  5 
   Need for information on how to determine and claim Federal Medical Assistance Percentage correctly  4 
   Need for information regarding Federal exchanges for States that have chosen not to run State exchanges  2 
   Delay in Federal review of documents  2 
   Need for information on National Information Exchange Management   1 
   Need for information regarding reasonable compatibility between self-attested information and data sources  1 
   continued on next page 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  14 
   
   
 
State-Reported Challenges To Implementing Streamlined Eligibility and Enrollment Requirements 
(Continued)  
Number of 
Challenge 
States Reporting 
Funding    
   Difficulty in allocating funds  6 
   Lack of funds  6 
   Delay in receiving funds from Federal Government  2 
Legislative and Policy Concerns    
Slow/difficult approval process within State legislatures  6 
 
   Need for resolution of legal uncertainty  3 
   Conflict between less stringent new Federal eligibility policies and more stringent State eligibility policies  3 
Policy conflicts and increased burden on State and consumers stemming from the streamlining of Medicaid 
   1 
but not other public assistance programs  
Timeframes    
   Aggressive timeframes  26 
   Not enough time to train staff  4 
Source:  Office of Inspector General analysis of State survey responses, 2012. 
 
   
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  15 
  APPENDIXC 
Agency Comments 
....".. 

(  t:. 	
~~J
c..
,.._  DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers lor Medicare & Medic:ald Services 
Offiu of tilt AdministT11tor 
DATE: 	 DEC  2 0 2U12  ~OC20201 
TO: 	 Daniel R. Levinson 

lnspec,tor General 

FROM: 	 ~l'avenner 

Acting Administrator 

SUBJECT: 	 Office of Inspector General (OIG) Draft Report:  ''Most States Anticipate 
Implementing Streamlined Eligibility and Enrollment by 2014" (OEI-07-10-00530) 
The Centers for Medicare &Medicaid Services (CMS) has reviewed the above mentioned draft OIG 
report.  While we do not have substantive or technical comments on the findings in the report. given 
the timing ofthe survey ofstates that was conducted, we would like to provide some further 
information and context for CMS's collective work with states to implement the changes needed to 
be ready for open enrollment for the Exchange. Medicaid and the Children's Health Insurance 
Program (CHIP) in October 2013. 
The OIG's report assesses the status of states' plans and efforts underway to meet the requirements of 
section 1413 of the Affordable Care Act. which involves changes to states eligibility and enrollment 
systems; application fonns; and eligibility data sharing capabilities across programs. OIG conducted 
a survey of states in April2012 to assess their readiness to implement these changes and also 
reviewed the guidance that CMS has provided to date.  The report notes that states indicated areas 
\\'here additional federal guidance is needed . Since that time. CMS has been engaged in a range of 
activities to assist states so that they will be ready for 2014. 
We appreciate OJG's efforts to identify the key areas of implementation that are critical to achieving 
readiness for 2014 and agree that CMS plays an important role in assisting states, through guidance 
and other technical assistance efforts, in meeting this timeframe.  In many states, readiness is being 
achieved through the work of many agencies, including Exchanges, Medicaid and CHIP entities.  As 
such, CMS has tailored its technical assistance and support activities according to the agencies 
engaged in each state. 
Following is an overview of the work that is currently underway to ensure that states and the federal 
government have the systems and policy tools in place to begin enrollment in October 2013. 
Additionally, on December I 0, 2012, the Department of Health and Human Services (HHS) 
announced the conditional approval of six states that applied early and are on track to meet all 
Exchange deadlines in order to setup their own state-based Exchange. These early approval states 
include: Colorado, Connecticut, Massachusetts, Maryland, Oregon, and Washington. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  16   
   
Agency Comments (Continued) 
   
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  17 
   
   
Agency Comments (Continued) 
   
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  18 
   
   
Agency Comments (Continued) 
 
 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  19 
   
   
Agency Comments (Continued) 
   
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  20 
   
   
Agency Comments (Continued) 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  21 
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian T. Pattison, Regional 
Inspector General for Evaluation and Inspections in the Kansas City regional 
office, and Brian T. Whitley, Deputy Regional Inspector General. 
Michala Walker served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Kansas City regional office who 
conducted the study include Michael Barrett, Jordan Clementi, and 
Rae Hutchison.  Central office staff who provided support include Kevin Farber, 
Kevin Manley, and Debra Roush. 
Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530)  22 
   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.