DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
 
DATE:   April 30, 2013  
 
FROM:   Cindy Mann, Director  
Center for Medicaid and CHIP Services  
 
SUBJECT:   Model Eligibility Application and Guidance on State Alternative 
Applications 
 
 
Today, the Centers for Medicare & Medicaid Services (CMS) is releasing the model single, 
streamlined application.  States may choose to use the model application, or may develop an 
alternative application that is approved by CMS. For states in which there is a Federally-
facilitated Marketplace the states Medicaid/CHIP agency will accept the model form and may, 
in addition, develop an alternative application approved by CMS.   
 
Beginning on October 1, 2013, the new Health Insurance Marketplace, also known as the 
Affordable Insurance Exchange, and State Medicaid and Childrens Health Insurance Program 
(CHIP) agencies will use a single, streamlined application to determine eligibility for enrollment 
into Qualified Health Plans (QHPs) and for insurance affordability programs including advance 
payments of the premium tax credit (APTCs), cost-sharing reductions (CSRs), Medicaid, and 
CHIP.  
   
This release has three components, which are all available for review at 
http://www.medicaid.gov/State-Resource-Center/Events-and-Announcements/Events-and-
Announcements.html.  The model online application will be available soon to the public:  
 
  Application for Health Coverage & Help Paying Costs (Short Form)  This paper 
application can be used by individuals who meet the criteria specified in the application to 
receive an eligibility determination for enrollment through the Marketplace or for Medicaid 
and CHIP. The form is accompanied by Appendix C Assistance with Completing this 
Application. 
 
  Application for Health Coverage & Help Paying Costs This paper application can be 
used to determine eligibility for an individual or family applying for enrollment through the 
Marketplace, Medicaid and CHIP. The Application for Health Coverage & Help Paying for 
Costs document is  accompanied by three appendices: 1) Appendix A: Health Coverage 
from Jobs and Employer Coverage Tool, assists employees in gathering the necessary 
information to answer employer sponsored health coverage questions on the application; 2)  CMCS Informational Bulletin  Page 2 
Appendix B American Indian or Alaska Native Family Member (AI/AN) provides specific 
guidance for the AI/AN community; and 3) Appendix C Assistance with Completing this 
Application includes general instructions for all applicants. 
 
  Application for Health Coverage  This paper application supports eligibility 
determinations for enrollment through the Marketplace for applicants who wish to be 
considered for coverage through a Qualified Health Plan (QHP) without financial assistance. 
The application for health coverage is also accompanied by Appendix C Assistance with 
Completing this Application. 
 
 
I.  Background 
 
Section 1413 of the Affordable Care Act directs the Secretary of Health and Human Services 
(HHS) to develop and provide to each state a single, streamlined form that applicants may use to 
apply for coverage in QHPs and insurance affordability programs, including APTCs, CSRs, 
Medicaid, and CHIP.  Individuals must be able to submit the application online, by mail, over the 
telephone or in person and the application may be submitted to a Marketplace, state Medicaid 
agency, or to a CHIP agency.  The application must be structured to maximize an applicants 
ability to complete the form satisfactorily, taking into account the characteristics of individuals 
who may qualify for the programs by developing materials at appropriate literacy levels and 
ensuring accessibility.  A state may develop and use its own single, streamlined application if 
approved by the Secretary. 
 
The Marketplace will begin accepting applications for coverage on October 1, 2013 for coverage 
that starts on January 1, 2014. This initial open enrollment period extends to March 31, 2014, but 
the Marketplace will also accept applications and make eligibility determinations (including a 
determination as to whether an individual qualifies for a special enrollment period) throughout 
the course of the year. Medicaid and CHIP agencies will also begin to use a single streamlined 
application on October 1, 2013.  As proposed in our January 22, 2013 Notice of Proposed 
Rulemaking (78 FR 4596) at 42 CFR 435.1205, Medicaid and CHIP agencies  must make 
available a single streamlined application as of October 1, 2013, in addition to their applications 
already in use for those who want to apply for coverage effective before January 1, 2014.  
 
Development of the Model Single, Streamlined Application  
In addition to the policy, operations and technology considerations employed during the 
development of the application, the model application materials directly reflect input received 
over several months through the public comment process provided for in the Paperwork 
Reduction Act (PRA), extensive consumer testing and state and other stakeholder consultation. 
  
  Public Comments: CMS published 30-day and 60-day PRA notices giving the public an 
opportunity to provide feedback on the application. This resulted in approximately 180 
comments largely focused on ideas for clarifying the wording of the questions and the 
information being requested from applicants.   
  CMCS Informational Bulletin  Page 3 
  Consumer Testing: CMS employed an iterative approach to testing the model application 
materials at several stages of development. CMS conducted multiple rounds of testing with 
individuals and small groups consisting of uninsured individuals and those who currently buy 
insurance on the individual market. These groups also varied by location, education level and 
income.   
 
  Stakeholder Consultation:  CMS sought input from a variety of stakeholders including state 
Medicaid, CHIP, and Marketplace officials; health insurance issuers; consumer advocates; 
and representatives of the American Indian and Alaska Native community. We also worked 
closely with partners from other federal agencies. 
 
 
II.  Guiding Principles for Application Development 
 
CMS adhered to the following basic principles as we designed the single, streamlined 
application.  These principles formed the basis for the design and content of the application 
materials and also informed forthcoming guidance for states on the parameters for development 
of alternative applications. 
 
  Minimize the burden on consumers.  The model application strives to make the enrollment 
process as simple as possible for applicants by collecting only the data necessary to 
determine eligibility.   
 
Integrate data sources to simplify the application process. A unique quality of the model 
online application is that it incorporates, through the process, eligibility verification that 
utilizes electronic data available through the new Federal Data Services Hub (Hub) as well as 
from other data sources.   
 
Provide help throughout the application process.  
The model online application provides easy references to help by displaying the call center 
telephone number in key locations as well as links to help in the community and on-line 
guidance.  
 
Process for Alternative Application Submission and Approval 
CMS is meeting regularly with states to provide technical assistance to State-based Marketplaces 
as well as Medicaid and CHIP agencies to facilitate adoption of the model application, or 
throughout the development of an alternative application.  CMS will share additional guidance 
with states about the review and approval of alternative applications in light of this release of the 
model single, streamlined application.  To request technical assistance or for questions relating to 
this guidance please contact Anne Marie Costello, Director, Division of Eligibility, Enrollment 
and Outreach, CMCS at 410-786-5175 or Hilary Dalin, Technical Advisor, State Exchange 
Group at 301-492-4343.