Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

MOST STATES ANTICIPATED 

IMPLEMENTING STREAMLINED

ELIGIBILITY AND 

ENROLLMENT BY 2014

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 Children’s 

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outdated eligibility and enrollment systems.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 Secretary’s 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 
 

Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530) 1

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 Children’s 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 

State3—an 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: CBO’s March 2012 Baseline, March 13, 2012. Accessed at 

http://www.cbo.gov/ on January 25, 2013. 5 ACA § 1413(e).
 

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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 State’s 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 Secretary’s 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) 3

• filed with any of a State’s 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 Secretary’s 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 

applicant’s eligibility.

12 Each State’s 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).
 

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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 1.0—describing 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 2.0—establishing a framework and approach for 

developing IT systems.18 

• Medicaid Program; Eligibility Changes Under the Affordable Care Act of 

2010—publishing 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 Children’s Health 

Insurance Program Agencies—presenting information on the data 

elements planned for inclusion in the Secretary’s 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 Children’s Health Insurance Program Agencies; Appendix A: Data Elements for 

Application to Support Eligibility Determinations for Enrollment through Affordable Insurance 

Exchanges, Medicaid and Children’s Health Insurance Program Agencies, July 9, 2012. 

Accessed at http://www.medicaid.gov on July 11, 2012.
 

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to eligibility determination systems.21 Under the amended regulations, approved 

States will receive a Federal matching rate of 90 percent of a State’s 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 State’s 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 Act’s 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) 6

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 Secretary’s 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 March–April 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. 
 

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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 

and matching by January 1, 2014

35 9 7 

Eligibility and Enrollment Systems

States that anticipate having systems that meet requirements related 

to eligibility and enrollment systems by January 1, 2014 38 5 8 

Application Forms

States that anticipate having application forms that meet requirements 

by January 1, 2014 40 2 9 

Data Sharing and Matching

States that anticipate implementing all eligibility data sharing

and matching requirements 37 5 9 

States that anticipate having secure electronic interfaces that meet 

requirements by January 1, 2014 37 5 9 

States that anticipate having data sharing and matching agreements 

that meet requirements by January 1, 2014 40 2 9 

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.
 

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Hampshire explained that it was having difficulty obtaining funding to make the 

necessary system changes. Oklahoma explained that the State’s 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 Secretary’s 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.
 

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Table 2: States’ Data-Sharing Agreements With Other State Agencies 

Agency Number of States With Data-Sharing 

Agreements 

Temporary Assistance for Needy Families 28

Vital Records Department 27

Supplemental Nutrition Assistance 

Program 27

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

Agency

Number of States With 

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 Secretary’s 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) 10

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 Secretary’s 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 

Secretary’s 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 Act’s Exchanges, Funding Opportunity Number: IE-HBE-10-001,

July 29, 2010. 
 

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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 Secretary’s 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 

the Secretary’s application form 7 

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 

State health subsidy programs 1 

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 Children’s Health Insurance Program (CHIP). Accessed 

at https://www.cms.gov on June 29, 2012.
 

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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 Court’s 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 Secretary’s 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 CMS’s 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) 13

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 

enrollment requirements by January 1, 2014* 44 7 

Eligibility and Enrollment Systems

Do you anticipate having a system that meets all requirements of section 1413 

related to eligibility and enrollment systems by January 1, 2014? 43 8 

Application Forms

Do you anticipate having an application form that meets the requirements of 

section 1413 by January 1, 2014? 42 9 

Have you decided whether you will develop a State-specific application form 

or use the Secretary’s application form? 40 11

Will you develop a State-specific application form or use the Secretary’s 

application form?** 10 0 

Data Sharing and Matching

States that anticipate implementing all eligibility data sharing and matching

requirements* 42 9 

Do you anticipate having a secure electronic interface that meets the 

requirements of section 1413 by January 1, 2014? 42 9 

Do you anticipate having data sharing and matching agreements that meet 

the requirements of section 1413 by January 1, 2014? 42 9 

Will your planned electronic interface allow determinations of eligibility for all 

of the State’s health subsidy programs based on the information provided on 

the single application form?

39 12

With which other agencies within the State do you currently have data-sharing 

agreements? 40 11 

With which Federal agencies do you currently have data-sharing agreements? 41 10 

Challenges

States that reported encountering challenges in implementing the streamlined 

eligibility and enrollment requirements* 45 6 

Guidance

Have you found the guidance available to date regarding implementation of 

streamlined eligibility and enrollment requirements helpful? 43 10

States that reported needing additional guidance to progress toward

implementation of the streamlined eligibility and enrollment requirements in 

section 1413*

45 6 

*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 Secretary’s 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) 14

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

Challenge Number of 

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 

Adjusted Gross Income (MAGI) and non-MAGI) 5 

 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 

enrollment 2 

 Reduction of available jobs for State/county workers because of increased efficiency of improved eligibility 

system 1 

Data Needs 

 Need for information on data elements available through the Federal data services hub and required on the 

Secretary’s application form 7 

 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 Secretary’s 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) 15

State-Reported Challenges To Implementing Streamlined Eligibility and Enrollment Requirements 

(Continued) 

Challenge Number of 

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 

but not other public assistance programs 1 

Timeframes 

 Aggressive timeframes 26

 Not enough time to train staff 4 

Source: Office of Inspector General analysis of State survey responses, 2012.
APPENDIXC 

Agency Comments 

~~·J ..."
..·c.. ( t:. 	DEPARTMENT OF HEALTH & HUMAN SERVICES 

,.._ 

DATE: 	 DEC 2 0 2U12 

TO: 	 Daniel R. Levinson 


lnspec,tor General 


FROM: 	 l'avenner 


Acting Administrator 


Centers lor Medicare & Medic:ald Services 

Offiu of tilt AdministT11tor 

~OC20201 

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 
 

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

Agency Comments (Continued)
 

Most States Anticipate Implementing Streamlined Eligibility and Enrollment by 2014 (OEI-07-10-00530) 22

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. 
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 OIG’s 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.