Wednesday, July 10, 2019

Sweeney's amendment to ACA exchange bill: Moar Medicaid enrollment integration?

Some clarification about what New Jersey state Senate president Stephen Sweeney was seeking when he held up passage of the bill to create a state ACA exchange -- other than leverage in bigger battles with Gov. Phil Murphy. 

After threatening not to allow a floor vote on the bill, Sweeney relented at the last minute after negotiating an amendment concerning integration of Medicaid processing in the platform. If the bill had not passed by the end of the legislative session, there would not have been time to meet federal requirements to get the exchange up and running in the fall of 2020 for enrollment in 2021.

Sweeney's amendment changed the language concerning Medicaid integration, directing the state to pursue federal funding for the integration. The text to be replaced is in brackets.

The Commissioner of 1[Banking and Insurance shall] Human Services1, in consultation with the Commissioner of 1[Human Services, examine whether federal financial participation is available for the exchange as a State administrative expenditure necessary for the proper and efficient administration of the State Medicaid plan. If the commissioner, in consultation with the Commissioner of Human Services, finds that federal financial participation is available and practicable, the commissioners shall, in consultation with one another, secure the maximum federal financial participation available] Banking and Insurance, shall submit a proposal for available federal financial participation funds to the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services pursuant to 42 C.F.R. 433.112 for the Medicaid eligibility platform and the exchange to be integrated.  Notwithstanding the foregoing, the Department of Banking and Insurance may proceed to implement the provisions of this act, including the operation of the State-based exchange.
A state exchange has to process applications for health insurance that qualify the enrollee for Medicaid on the basis of income. At present, the federal exchange,, makes a determination of Medicaid eligibility for qualifying New Jersey applicants and sends it to the state Medicaid agency for processing. Sweeney's amendment mandates the state agencies, Human Services and Banking and Insurance, to seek federal funding for a deeper Medicaid integration -- a system that could process all Medicaid applications, not just those enabled by ACA Medicaid expansion rules, which qualify anyone with income under 138% of the Federal Poverty Level.

The statute referenced, 42 C.F.R. 433.112, provides for 90% federal funding  for design and development of a Medicaid "eligibility and enrollment system." New Jersey tapped that federal match in 2009 to build a new Medicaid enrollment platform that became a massive boondoggle and was terminated in 2014.  The failure resulted in huge processing delays when the ACA launched in 2014 and hundreds of thousands of new enrollees signed up.    Sweeney is effectively directing the state to try again.

Federal funding is not available for development of a state exchange -- the funding stipulated by the ACA expired on Dec. 31, 2014.  According to Chini Krishnan, CEO of IT vendor GetInsured, which has built several state exchanges including California's, the key to success in exchange buildout is to start small, use the federal exchange's protocols for account transfer, and integrate enrollment only for those qualified by ACA Medicaid expansion income criteria.  Deeper integration can (must) come later.

Crucially, the last sentence of Sweeney's amendment stipulates that building out the exchange is not contingent on obtaining federal funding for a more thorough Medicaid enrollment/eligibility buildout. The agencies charged with getting the exchange built can start with the basics.

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