EDITOR’S NOTE: On May 17, 2013, the Centers for Medicare and Medicaid Services (CMS) issued guidance alerting states that waivers would be available to facilitate the enrollment of eligible individuals into Medicaid using data states already had available in their Supplemental Nutrition Assistance Program (SNAP) and Medicaid files. Manatt has prepared a “roadmap” for the Robert Wood Johnson Foundation State Health Reform Assistance Network, detailing the process for securing a fast track waiver from CMS and providing additional strategies states may want to pursue. Below is a summary of key points. Click here to download the full roadmap, including samples of enrollment forms. Manatt also prepared a related issue brief for the Henry J. Kaiser Family Foundation. Click here to download the issue brief.

The CMS guidance allowing waivers to facilitate enrollment into Medicaid using information states already have “on hand” in SNAP and existing Medicaid files offers several key advantages. States securing a fast track waiver can:

  • Efficiently and quickly enroll eligible individuals in coverage
  • Alleviate the administrative demands of new eligibility and enrollment systems for Medicaid and the Marketplaces
  • Reduce the staff time required to process Medicaid applications

With the fast track waiver, states expanding Medicaid to new adults with incomes up to 133% of the federal poverty level (FPL) have a powerful tool for streamlining the enrollment process.

How to Apply for a Fast Track Waiver

CMS has established a simple process for applying for fast track waivers. (States can apply any time through December 15.) The waiver request can consist of a short letter to CMS, accompanied by, if needed, clarifying emails or phone calls. States must provide at least the following information:

  • Why the state needs the waiver to improve its eligibility and enrollment system and meet is administrative obligations
  • How the state will secure a signature from fast track enrollees—physically, electronically or telephonically
  • How the state will obtain and verify missing information
  • How the state will ensure people receive information on their rights and responsibilities, third-party liability and medical support requirements
  • How the state can ensure it will evaluate fast track enrollees using the Modified Adjusted Gross Income (MAGI) rule within a year of enrollment—or earlier if there is a change in circumstances
  • What the duration of the waiver is

CMS has indicated it will provide states with sample waiver language, if needed. Once CMS approves the waiver, it will send a letter to the state confirming its eligibility.

Key Steps for Early Adopters to Operationalize Fast Track

States have broad discretion in operationalizing fast track enrollment. The basic steps states have used to date include:

Step 1: Identifying eligible individuals
In the basic version of fast track aimed at enrolling non-disabled, non-elderly adults, states have identified eligible individuals as those between 19 and 64 with incomes below 133% FPL who are not currently enrolled in Medicaid or receiving Supplemental Security Income (SSI) benefits. Variations to the basic approach have been to include children or focus exclusively on adults without children.

Step 2: Designing a fast track enrollment form
Fast track enrollment forms advise SNAP enrollees of their new opportunity to enroll in Medicaid. They also ensure that states have the information and authorization they need to establish eligibility for coverage. States that already have implemented fast track enrollment have included the following information on their forms:

  • The good news about the chance to enroll quickly and easily for coverage
  • The specific steps for enrolling, such as signing and returning the form by a specified date
  • A place for applicants to sign and date the form, provide contact information and, if needed, supply any missing information, such as verification of citizenship or immigration status
  • The date coverage begins
  • The applicant’s rights and responsibilities, as well as information about third-party liability and medical support requirements
  • “Next steps,” such as when the applicant will receive confirmation of coverage
  • A phone number people can call, if they have questions
  • A client ID number to help identify returned forms

States may choose to supplement or modify forms. Variations on the standard form have included asking if the consumer has alternative coverage; sending one form for all eligible family members, rather than a separate form for each individual; and informing applicants that any uninsured family members not listed on the form can apply for coverage online.

Step 3: Processing returned forms
Once a state receives fast track enrollment forms, it must verify citizenship and immigration status in accordance with Medicaid requirements. Verification steps depend on whether the fast track enrollee is identified through SNAP or Medicaid.

  • For SNAP beneficiaries: Since SNAP and Medicaid use different citizenship verification rules, states must confirm the citizenship of fast track enrollees according to Medicaid. Medicaid rules require electronic verification through the federal data hub using social security numbers or the Systematic Alien Verification for Entitlements (SAVE) program if the hub is down. In contrast, SNAP uses the same verification requirements as Medicaid for legal immigration status, so states don’t have to verify that information for SNAP fast track enrollees.
  • For parents of Medicaid children: States often lack citizenship and immigration status information for fast track enrollee parents using Medicaid data for their children. When that data is missing, states need to gather it and confirm eligibility, unless they already have it on file.

If a state can’t verify citizenship or legal immigration status, it must deny coverage to the fast track applicant.

Step 4: Confirming eligibility and providing follow-up information
After an individual’s citizenship or immigration status is verified, states send confirmation of eligibility for coverage and, if applicable, information on how to select a plan.

Step 5: Conducting a full MAGI determination
CMS expects states to evaluate fast track enrollees under MAGI rules within a year of their enrollment in Medicaid. If enrollees report a change in circumstance before their renewal date, their eligibility must be assessed under MAGI rules.

Implementation Steps Identified by Early Adopters

The four states already implementing fast track have identified some additional strategies to increase its effectiveness. Some extra steps that can help improve the process include:

  • Following up with non-responders using phone calls or other outreach methods
  • Conducting citizenship verification prior to sending fast track enrollment forms
  • Re-checking whether fast track enrollees already are enrolled in Medicaid to avoid duplicate enrollments
  • Using a centralized unit or specially trained team to process fast track applications
  • Integrating Affordable Care Act (ACA) marketing and logos to help consumers understand how fast track fits into broader reform efforts

Conclusion

CMS has given states significant flexibility in how they choose to implement fast track. State can tailor their fast track strategies to their needs, regardless of how they choose to operationalize the Medicaid expansion. For example, Arkansas combined its use of fast track with a private option under which it uses Medicaid funds to support beneficiaries in selecting a private Marketplace plan.

Manatt is continuing to monitor Medicaid developments. We will be sharing the latest trends in Medicaid next month.