The Affordable Care Act (ACA) establishes a ‘no wrong door’ enrollment policy that aims to enable people seeking coverage to complete one application to determine which health and social services programs they and their family are eligible for.

The policy will allow individuals to figure out eligibility, and enroll in federal and state health insurance affordability programs, including premium subsidies, cost-sharing reductions, Medicaid, and CHIP.  Technology will be used to mask the multi-agency, multi-system complexity and enable agencies to coordinate behind the scenes to provide consumers a single, seamless eligibility determination and enrollment process.

The federal government suggests that states address eligibility and enrollment modernization efforts using a phased approach — implementing health benefit exchange, Medicaid and CHIP components first, then adding eligibility determination and enrollment capabilities for other federally funded programs such as Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF).  By building a robust infrastructure, additional services such as child care, child support, child welfare, behavioral health, long-term care and other support services can be added — making it possible for consumers to arrive at ‘no wrong door.’

Under the ACA, system development costs are covered by the federal government — at 100 percent for State-based exchanges, 90 percent for Medicaid, and at administrative funding levels for CHIP.  To encourage states to develop more integrated eligibility determination and enrollment systems, in August 2011 the Department of Health and Human Services (HHS), the Department of Agriculture (USDA), and the Center for Medicare and Medicaid Services (CMS) jointly announced a time-limited, enhanced funding program. The program provides states an unprecedented opportunity to make the most of healthcare reform by allowing federally-funded human services programs to benefit from investments made in state eligibility systems being developed by state-operated Exchanges, Medicaid, and CHIP, without benefiting programs having to share in the common system development costs.

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This is a break from the usual practices under OMB Circular A-87 and allows enhanced system development federal financial participation to be used for system components that are shared. The A-87 exception ruling encourages states to develop horizontal linkages between health and human services — resulting in improved customer care and lower administrative costs.

Path to no wrong door
Under the OMB A-87 Exception, states can receive enhanced 90 percent Federal Financial Participation (FFP) for expenditures for the design, development, installation, or enhancement of eligibility determination systems through calendar year 2015. States wishing to leverage this funding opportunity need to obtain federal approval through the Advanced Planning Document (APD) process. Details about the work to be performed, how it will be tracked and measured, costs, timelines, and technical activities and requirements must be documented and approved. States must incur costs for goods and services furnished no later than December 31, 2015 and approved development, design, installation and enhancement must be completed by the end of calendar year 2015.

After 2015, enhanced FFP at the 75 percent rate is available for costs affiliated with the maintenance and operation of systems that previously qualified for 90 percent FFP.  States that choose not to receive enhanced funding through calendar year 2015 can receive 50 percent FFP for systems developed, installed or enhanced after calendar year 2015 and will continue to receive 50 FFP for any maintenance and operations conducted on these systems.

To leverage enhanced funding available through the A-87 Exception, eligibility and enrollment projects have to: (1) be modular; (2) advance the Medicaid Information Technology Architecture (MITA) principle; (3) meet specified industry standards; (4) promote sharing, leverage and reuse of Medicaid technologies of systems within and among States; (5) support business results; (6) meet program reporting; and (7) ensure seamless coordination and integration with the Health Insurance Exchange (HIX) and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.

Time to act
While much progress has been made to meet the initial requirements of the ‘no wrong door’ policy, come January, 2014 when Exchanges and Medicaid programs must be operational, very few states will be rolling out a truly ‘no wrong door’ offering that includes SNAP and TANF.

To move further along the integration continuum, states must keep the end goal in mind and take advantage of the federal dollars available for modernizing and building new administrative efficiencies into their systems. 

They must establish a clear integrated vision where unified health and human service systems operate seamlessly. Human services program managers must collaborate with Medicaid and Exchange organizations to identify requirements and jointly establish design and implementation plans to ensure necessary capacity is built into future systems. Time available to take advantage of these unprecedented funding opportunities is limited, so states must act quickly.

States are not the only entities that need to up their game, however, the federal government must continue to provide leadership and collaboration to support client-centered health and human services interoperability. Additional guidance and resources aimed at clarifying policy and reducing confusion is essential. At the federal level, the Centers for Medicare and Medicaid Services must work with the Food and Nutrition Service and other federal partners to ensure that information gathered and used to verify eligibility can be shared across programs; a truly consumer-centric solution can only be achieved if program requirements are aligned.

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The federal government must also ensure that states are taking the necessary steps to deliver upon the goals stated in their approved APD plans. It will be critical for the federal government to ensure the funds awarded to states yield the stated outcome.  The federal government must also enforce stronger language and policy as far as what integration needs to be done and by when.

Additionally, the federal government must establish a commitment to reuse and knowledge sharing, training, education, guidance and improved communication if states are to succeed.  Where possible common system functionality and features should be shared across health and human services agencies at the federal and state level; the verifications and other services offered through the Federal Data Services Hub are a good place to start.

Turning vision to reality
Today, we as a nation have an unprecedented opportunity to transform, modernize and integrate how consumers access health and social services. By leveraging technology innovation — and the funds available through the A-87 Exception ruling — we can not only reap the healthcare benefits presented by the ACA, but also bridge the gap between health and social services.

If states take the necessary action, we can transform the underpinnings of the nation's eligibility and enrollment systems and remove the redundancy that too often imposes unnecessary burdens on consumers and state workers. Leveraging the existing funds available, we can replace our much antiquated systems and strive to achieve wellness rather than just treat illness.

Expanded access and better health outcomes for consumers will yield a reduction in the nation’s future health care costs. Now is the time to turn the vision into reality.

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