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Determine Member Eligibility

Member Enrollment

Description

The Determine Member Eligibility business process is responsible for the operational aspects of determining if an applicant is eligible for Medicaid or potentially eligible for other insurance affordability programs (e.g., Advance Premium Tax Credits through the Health Insurance Marketplace (HIX) commonly referred to as the Marketplace. Children’s Health Insurance Program [CHIP], and/or Basic Health Program [BHP]). An applicant submits an application or a member updates account information via online, in person, over the phone, by mail, or by other commonly available electronic means. The business process checks for status (e.g., new, resubmission, redetermination, duplicate, or referral from the Health Insurance Marketplace or other agencies administering insurance affordability programs) and verifies applicant information in accordance with the policies established. The business process determines eligibility based on modified adjusted gross income (MAGI) or on a basis other than MAGI methods including group/category (e.g., parents/caretaker relatives, pregnant women, children under 19 year of age). The business process also assigns a Medicaid ID, associates the benefit packages, and produces notifications for coordinated communications. When required, the State Medicaid Agency (SMA) submits applicant or member eligibility information and/or eligibility determination to other agencies administering insurance affordability programs and CMS information systems. This business process could be a Shared Eligibility Service between the Medicaid Agency, the Health Insurance Marketplace, and other State-based insurance affordability programs such as CHIP or BHP. NOTE: Applications and Accounts: An individual seeking eligibility for enrollment in an insurance affordability program completes and submits an application on-line, in person, over the phone, by mail, or paper application for verification and eligibility determination. Accepted application data is managed in an “electronic account” (as defined in 42 CFR 435.4) by the receiving program to enable access to this information during the verification and eligibility determination processes, as well as after the conclusion of the process to support change reporting and for other purposes.

Business Process Template

Trigger events
Environment-based
  • Receive application via online, in person, over the phone, by mail, or other commonly available electronic means.
  • Periodic timetable (e.g., annual) for existing member who is due for redetermination of eligibility. Applicant or authorized representative responds to renewal form by providing information via online, in person, over the phone, by mail, or other commonly available electronic means.
  • Receive modification to application from applicant or authorized representative or change report from member or authorized representative or from other data sources.
Interaction-based
  • Receipt of referral of Medicaid applicant from the Health Insurance Marketplace, CHIP or BHP.
  • Receipt of individuals based on Auto-Eligibility, such as Deemed Newborns, SSI/1634, Title IV-E Foster Care, Adoptions and Guardianship.
Results
  • Eligibility is determined as approved, continued, denied, terminated, suspended, or pended for additional information and review.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • Full Eligibility Determination or Renewal
  • 1. START: a. Receive completed application from applicant via online or by other commonly available electronic means, in person, over the phone, or by mail, or receive initial assessment from another insurance affordability program; or NOTE: The use of the internet website (online portal) will include not only field-level edits but will also perform data verification, as appropriate, throughout the application preparation and update process as well as determine if the account already exists (in the Health Insurance Marketplace, Medicaid and/or CHIP) and the status of application/account. b. Initiate renewal process when member’s response to renewal notice is received or when changes to existing member account is updated with new information from other data source(s); or c. Receive information about an auto-eligible. Go to Alternate Scenario 1. NOTE: Conduct steps 2, 3, and 4 simultaneously or in any order in accordance with State’s established verification plan (42 CFR 435.945(j)). Financial Information will be verified if financial assistance is requested and the information is provided. Verify asset information if applicant has requested to be evaluated for Medicaid eligibility based on a non-MAGI group that requires an asset test.
  • 2. Verify the following non-financial requirements for eligibility determination. CMS expects the State to use Federal or local electronic data sources as available. The State may also rely on self-attestation for all eligibility criteria other than citizenship and satisfactory immigration status, as described in Section H of the preamble of the Medicaid Final Eligibility Rule. Resolve discrepancies by identifying non-financial factors that do not meet verification based on data matches or self-attestation and request additional information as necessary. a. Verify State residency. b. Verify the SSN. c. Verify citizenship or satisfactory immigration status. d. If applicable, verify whether individual is an American Indian/Alaska Native, in accordance with established procedure. Note: American Indian/Alaska Native status is not a condition of eligibility for Medicaid. e. If applicable, verify individual incarceration status. Note: Incarceration status is not a condition of eligibility for Medicaid. f. Pregnancy. Note: The Agency must accept self-attestation of pregnancy unless the State has information that is not reasonably compatible with such attestation. g. Age, date of birth and household size. Note: The Agency may accept self-attestation of date of birth and the individuals that comprise an individual’s household or may verify through other reasonable verification procedures. h. Other non-financial factors (e.g., full-time student status, categorical eligibility as a parent or other caretaker relative as defined in 42 CFR 435.4).
  • 3. Verify enrollment in other health coverage, including Medicare, other public programs, as well as private coverage. Note: Enrollment in private health coverage is not a barrier to Medicaid eligibility except as an optional targeted low-income child or as a woman needing treatment for breast or cervical cancer. Medicare recipients are exempted from certain eligibility groups, while Medicare coverage is required for certain other eligibility groups.
  • 4. Verify financial information (42 CFR 435.948) provided by the applicant or member, including: a. Information related to wages, net earnings from self-employment, and unearned income and resources with the appropriate source (e.g., State Wage Information Collection Agency (SWICA), IRS, Social Security Administration, State unemployment compensation, and State-administered supplementary payment programs) b. Information related to the eligibility or enrollment from the Supplemental Nutrition Assistance Program, the State program funded under part A of Title IV of the Act, and other insurance affordability programs.
  • 5. Verify asset information if applicant has requested to be evaluated for Medicaid eligibility based on a non-MAGI group that requires an asset test.
  • 6. Use results from verification processes and other application data to assess and determine whether the individual meets the non-financial factors for eligibility: a. If individual meets residency requirement, go to Step 6b. If not, go to Step 12 to deny Medicaid. b. If individual is a verified citizen, go to Step 6d. If not, continue to Step 6c. c. If individual meets satisfactory immigration status requirements, go to Step 6d. If not, flag individual for coverage of emergency medical services and proceed to Step 6d. d. If individual is requesting only a non-MAGI eligibility determination, go to Step 10 to screen for non-MAGI. If not, go to Step 6e. e. If individual is under age 65 or a parent / caretaker, go to Step 7 to assess and determine eligibility for mandatory MAGI. If not, go to Step 10 to screen for potential non-MAGI eligibility.
  • 7. Determine individual’s eligibility based on mandatory MAGI eligibility groups. Note: See Mandatory MAGI Groups Table 1. a. Assess whether the applicant/member is eligible as an infant or a child under the age of 19. (42 CFR 435.118). If yes, go to Step 7f. If not, go to Step 7b. b. Assess whether the applicant/member is eligible as a parent or other caretaker relative (42 CFR 435.110). If yes, go to Step 7f. If not, go to Step 7c. c. Assess whether the applicant/member is eligible as a pregnant woman (42 CFR 435.116). If yes, go to Step 7f. If not, go to Step 7d. d. Assess whether the applicant/member is eligible as a former foster care child (no income test) (42 CFR 435.150). If yes, go to Step 7f. If not, go to Step 7e. e. Assess whether individual is age 19 or older and under age 65, not pregnant, is not receiving Medicare (42 CFR 435.119) and is therefore eligible as part of “the adult group”. If yes, go to 7f , if not, go to Step 8 to assess individual for optional MAGI groups. f. If individual is flagged for emergency medical services only, go to Step 14 to assign groups and benefit level (limited coverage for emergency services). If not, go to Step 9 to assess and determine Medicare Savings Program (MSP) eligibility prior to assigning groups and benefit level (however, if the individual is determined eligible as part of the “adult group” they will pass through Step 9 to Step 14).
  • 8. Assess and determine individual’s eligibility based on optional MAGI groups. States may choose to offer any or all of the optional groups listed in Table 2. Verify (by self-attestation or otherwise) any additional non-financial factors of eligibility for the relevant optional group(s). a. If an individual meets non-financial factors and income standards for an optional MAGI group, go to Step 8b. If not, go to Step 10 to screen for potential non-MAGI eligibility. b. If individual is flagged for emergency medical services only, go to Step 14 to assign groups and benefit level (limited coverage for emergency services). If not, go to Step 9 to assess and determine Medicare Savings Program (MSP) eligibility prior to assigning groups and benefit level.
  • 9. Prior to approving or denying Medicaid eligibility, assess and determine if individual is eligible for a Medicare Savings Program. Note: See Medicare Savings Program Groups Table 3. a. Determine if individual is enrolled in Medicare Part A or B. If enrolled in Medicare Part A or B, go to Step 9b. If not, go to Step 9c. b. Determine if individual is eligible for a Medicare Savings Program Group. If the individual is eligible based on MSP criteria, go to Step 14 to assign groups and benefit level. If not, go Step 9c. c. If individual was previously determined eligible on another basis, go to Step 14 to assign groups and benefit level. If not, go to Step 12 to deny Medicaid.
  • 10. Screen individual for potential non-MAGI eligibility based on application information: a. If individual has requested a non-MAGI eligibility determination or application data indicates potential eligibility for non-MAGI (e.g. indicators of disability, blindness, aged, or a need for long term care services), go to Step 11 to determine eligibility on basis other than MAGI. If not, go to Step 10b. b. If individual was previously determined eligible based on MAGI, no further action required. If not, go to 10c. c. If individual is flagged for emergency medical services only, go to Step 12 to deny Medicaid. If not go to Step 9 to assess and determine Medicare Savings Program (MSP) eligibility NOTE: Although the individual was flagged for emergency medical services, the individual has failed all other income tests and the screening for potential non-MAGI and should be denied coverage for emergency medical services.
  • 11. Determine individual’s eligibility on basis other than MAGI. Note: See Optional Non-MAGI Groups Table 4, Age, Blind, Disabled (ABD) Optional Coverage Groups Table 5 and Medically Needy Groups Table 6. a. Determine if information is sufficient for a near real-time determination. If yes, go to Step 11c. If not, go to Step 11b. b. Request additional information from applicant, member, or authorized representative (e.g., electronic verifications for former foster care children). Proceed to Step 11d; and if necessary, transmit account (Manage Member Information) to the Health Insurance Marketplace for interim coverage. c. Determine if further verifications are necessary. If yes, go to Step 11d. If not, go to Step 11e. d. Verify additional non-financial and financial information (income and assets), as appropriate, according to methodologies for applicants or members who may be eligible on basis other than MAGI. Go to Step 11e. e. If individual is eligible on a basis of other than MAGI, go to Step 11h. If not, go to Step 11f. f. If individual was previously determined eligible based on MAGI, no further action is required. If not, go to 11g. g. If individual is flagged for emergency medical services only, go to Step 12 to deny Medicaid. If not, go to Step 9 to assess and determine Medicare Savings Program (MSP) eligibility. NOTE: Although the individual requested coverage for emergency services, the individual has failed all income tests (MAGI and non-MAGI) and should be denied Medicaid.. h. If individual is flagged for emergency medical services only, go to Step 14 to assign groups and benefit level (limited coverage for emergency services). If not, go to Step 9 to assess and determine Medicare Savings Program (MSP) eligibility prior to assigning groups and benefit level.
  • 12. Deny Medicaid eligibility, update account (ME-01 Manage Member Information) and notify individual (Manage Applicant and Member Communication) of determination.
  • 13. Assess individual for other Insurance Affordability Programs a. Assess for potential eligibility in other insurance affordability programs. If individual is potentially eligible for other insurance affordability program refer/notify CHIP and/or Health Insurance Marketplace as applicable. (Manage Member Information). If not, no further action required.
  • 14. Assign group and benefit levels as appropriate. a. Assign Medicaid identification number to member if one was not previously assigned. b. Assign individual to one or more eligibility groups based on their eligibility determination: MAGI group, Non-MAGI group, and/or Medicare Savings Program (MSP) group. NOTE: Individual can be assigned to a Medicare Savings Program (MSP) group and another eligibility group (i.e. MAGI or non-MAGI). However, an individual cannot be assigned to both a MAGI and non-MAGI group simultaneously. An individual also cannot be assigned to an MSP group and receive coverage for emergency services simultaneously. c. Flag individuals determined eligibile for emergency medical services. NOTE: Individuals eligible for coverage of emergency medical services will receive a limited benefit plan. d. If the individual was determined eligible for MAGI go to Step 10 to screen individual for non-MAGI eligibility and proceed to 14e. If not, the individual was determined eligible based on non-MAGI, continue to 14e. e. Determine the health benefit level the member is eligible to receive and then proceed to 14f. f. Go to Enroll member, to enroll individual in the appropriate eligibility group(s); and determine if individual was approved for a group that provides minimum essential coverage. If yes, individual is approved for a group that provides minimum essential coverage, go to 14g. If no, refer to CHIP and/or Health Insurance Marketplace as applicable (Manage Member Information); and notify individual (Manage Applicant and Member Communication) of determination. g. If individual is currently enrolled in CHIP or the Health Insurance Marketplace, notify CHIP and/or the Health Insurance Marketplace as applicable of individual’s enrollment in Medicaid for potential disenrollment; and notify individual (Manage Applicant and Member Communication) of determination. If not currently enrolled in CHIP orHealth Insurance Marketplace, notify individual of determination.
  • 15. END
  • Alternate Scenario 1 - Auto Eligible
  • 1. Determine if applicant or member is automatically categorically eligible without a requirement for financial eligibility (e.g., SSI recipients, IV-E children, deemed newborns). Assess if the individual is a State resident. If so, approve Medicaid eligibility and go to step 14. If not, go to step 6. Note: See Mandatory Auto Eligible Groups Table 7.
Predecessor processes
  • Receive Inbound Transaction
  • Manage Applicant and Member Communication
Successor processes
Shared data
  • Member data store including demographics and enrollment information
  • Plan data store
  • Coordination of Benefits data store
Constraints

The Determine Member Eligibility business process must be in accordance with federal rules for standard enrollment application and eligibility determination. The State must use minimum and maximum income standards established by the Agency in the Medicaid State Plan.

Failures
  • Duplicate or cancelled application.
  • Applicant or member fails to provide additional information as requested.
  • Required fields missing or not correct.
  • Verification with internal or external sources is not authenticated. Note: The Determine Member Eligibility business process does not fail because the applicant is ineligible.
Performance measures
  • Enroll Member

Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 1-16.

Business Capability Model (10 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Is the process primarily manual or automated?
  1. LEVEL 1All applications require human involvement. All verifications require applicants to submit paper documentation.
  2. LEVEL 2All applications require human involvement; staff accesses verification information from electronic data sources.
  3. LEVEL 3SMA adjudicates modified adjusted gross income (MAGI) eligibility for the majority of applicants without human involvement. SMA uses a well-developed automated interface with the Marketplace and CHIP agency. SMA uses interface to transmit case information without human involvement. SMA automates verification for MAGI eligibility and integrates into online application. SMA automates verification for MAGI population to the maximum extent possible. SMA manually executes verification for non-MAGI eligibility.
  4. LEVEL 4SMA adjudicates MAGI eligibility for the majority of applicants without human involvement. SMA participates in a shared eligibility service with the Marketplace and CHIP agency that eliminates the need for any interfaces to support eligibility based on MAGI. SMA automates verification for MAGI population to the maximum extent possible. SMA manually executes verification for non-MAGI eligibility.
  5. LEVEL 5SMA adjudicates MAGI eligibility for the majority of applicants without human involvement. SMA participates in a shared eligibility service with the Marketplace and CHIP agency that accommodates MAGI and non-MAGI eligibility. SMA only utilizes manual processes when electronic verification is not possible.
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of national (e.g. HIPAA) and state-specific standards.
  3. LEVEL 3SMA adopts national standards (e.g. HIPAA, Administrative Simplification, Health Information Technology Enrollment and Standards Protocols) for exchange of eligibility information.
  4. LEVEL 4SMA adopts national standards (e.g. HIPAA, Administrative Simplification, Health Information Technology Enrollment and Standards Protocols) and actively participates in the ongoing development of related standards.
  5. LEVEL 5SMA adopts national standards (e.g. HIPAA, Administrative Simplification, Health Information Technology Enrollment and Standards Protocols), actively participates in the ongoing development of related standards, and works with other States and Federal Government to develop and adopt standards related to eligibility process, not limited to data exchange.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2The SMA collaborates with other agencies and entities to adopt HIPAA standards and EDI transactions.
  3. LEVEL 3SMA adopts a well-developed data sharing arrangement with the Marketplace and CHIP agency that includes a shared understanding of workflow and a process for issue resolution. The SMA documents the arrangement in an agreement. The SMA maintains effective relationships with state and federal data sources to support verification.
  4. LEVEL 4SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage the shared eligibility service and to conduct joint planning and population management efforts. The SMA documents the arrangement in an agreement that is dynamic and updated as conditions change.
  5. LEVEL 5SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage the shared eligibility service and to conduct joint planning and population management efforts. The SMA documents the arrangement in an agreement that is dynamic and updated as conditions change. The SMA works with state and national data sources to establish data exchanges and supporting activities with programs in other States.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1SMA sometimes meets threshold or mandated requirements for timeliness (e.g., the process achieves results within the time specified by law, or regulation). SMA takes multiple weeks to complete paper handling and does not have the capacity to adjudicate eligibility without human intervention.
  2. LEVEL 2SMA improves timeliness through use of automation. Timeliness always meets requirements. To the extent that SMA requires paper, it takes multiple weeks to complete paper handling.
  3. LEVEL 3SMA improves timeliness through increased use of automation. When electronic data is available and consistent with an applicant’s attestation, applicants who submit the single, streamlined application electronically receive a MAGI determination in near real-time. When necessary, the SMA also transmits electronic application information to agencies administering other insurance affordability programs in near real-time. SMA accepts scanned documents, but takes multiple days or weeks to adjudicate documentation where necessary.
  4. LEVEL 4SMA further improves timeliness through increased use of automation. When electronic data is available and consistent with an applicant’s attestation, applicants who submit the single, streamlined application electronically receive a MAGI determination in near real-time. SMA decreases the time required for determinations that involve other insurance affordability programs using a shared eligibility service. SMA accepts scanned documents, and adjudicates all documents for MAGI-based eligibility within 72 hours of receipt, which further improves timeliness over Level 3.
  5. LEVEL 5SMA further improves timeliness through increased use of automation. When electronic data is available and consistent with an applicant’s attestation, applicants who submit the single, streamlined application electronically receive a MAGI determination in near real-time. SMA decreases the time required for determinations that involve other insurance affordability programs or non-MAGI eligibility using a shared eligibility service. SMA accepts scanned documents, and adjudicates all documents for MAGI-based eligibility within 24 hours of receipt, and minimizes the time required to adjudicate documents for non-MAGI eligibility.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
  2. LEVEL 2SMA uses electronic information improving accuracy of information but the decision-making process may be erroneous or misleading and human involvement leads to incorrect information. Accuracy is higher than at Level 1.
  3. LEVEL 3SMA adopts automation of verification process and eligibility determination based on MAGI, which eliminates the vast majority of human error from the process. Accuracy challenges still exist in the manual processing of documentation, but SMA reduces errors as much as possible through standard operating procedures.
  4. LEVEL 4SMA adopts automation of verification process and eligibility determination based on MAGI, which eliminates the vast majority of human error from the process. SMA uses shared eligibility service to eliminate inaccuracy in application of rules across insurance affordability programs. Accuracy challenges still exist in the manual processing of documentation, but SMA reduces errors as much as possible through standard operating procedures and increased reliance on electronic data.
  5. LEVEL 5SMA adopts automation of verification process and eligibility determination for MAGI and non-MAGI, which eliminates the vast majority of human error from the process. SMA uses shared eligibility service to eliminate inaccuracy in application of rules across insurance affordability programs. Accuracy challenges still exist in the manual processing of documentation, but SMA reduces errors as much as possible through standard operating procedures and maximum use of electronic data.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.Verification requires manual contact via telephone, facsimile, or mail. Systems experience extended scheduled and unscheduled downtime.
  2. LEVEL 2SMA stores information in disparate systems, but use of electronic information, automation and HIPAA standards increase accessibility over Level 1. Systems experience extended scheduled and unscheduled downtime.
  3. LEVEL 3SMA easily exchanges and uses information from the Marketplace, CHIP, Basic Health Program (BHP), and local data sources upon request based on MITA Framework and industry standards. SMA maintains individual information in an electronic account that is accessible to the individual for review and self-service. Self-service for non-MAGI individuals is limited. Electronic account is available 24/7 through the portal except during state-approved maintenance timeframes.
  4. LEVEL 4SMA has full access to Marketplace, CHIP, and BHP information through use of shared eligibility service. SMA maintains individual information in an electronic account shared across insurance affordability programs that is accessible to the individual for review and self-service. Self-service for non-MAGI individuals is limited. Electronic account is available 24/7 through the portal except during state-approved maintenance timeframes.
  5. LEVEL 5SMA has full access to Marketplace, CHIP, and BHP information through use of shared eligibility service. SMA maintains individual information in an electronic account shared across insurance affordability programs that is accessible to the individual for review and self-service. Electronic account is 24/7 through the portal except during state-approved maintenance timeframes.

Business Capability Quality: Cost Effectiveness

What is the ratio for the cost of eligibility determination compared to the value of the results?
  1. LEVEL 1High relative cost due to low number of automated, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, increasing cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts Seven Standards and Conditions, MITA Framework, industry standards, and other nationally recognized standards further increasing cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA participates in shared eligibility service. SMA adopts Seven Standards and Conditions, MITA Framework, industry standards, and other nationally recognized standards for regional information exchange. SMA increases cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts national (and international) standards for information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and agency performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3Reliance on automated processes improves efficiency to 90% or higher.
  4. LEVEL 4Use of shared eligibility service for MAGI population improves efficiency to 95% or higher. .
  5. LEVEL 5Use of shared eligibility services for all populations improves efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1SMA applies business rules manually and inconsistently, producing inconsistent and incorrect results.
  2. LEVEL 2SMA applies some automated business rules, which increases accuracy. Results remain inconsistent based on mix of automated and manual processes. Accuracy is higher than at Level 1.
  3. LEVEL 3SMA automates the verification and eligibility determination for MAGI populations, eliminating the vast majority of human error from the process. Accuracy challenges still exist in the manual processing of documentation, but SMA reduces errors as much as possible through standard operating procedures.
  4. LEVEL 4SMA automates the verification and eligibility determination for MAGI populations, eliminating the vast majority of human error from the process. SMA uses shared eligibility service, eliminating inaccuracy in application of rules across insurance affordability programs. Accuracy challenges still exist in the manual processing of documentation, but SMA reduces errors as much as possible through standard operating procedures.
  5. LEVEL 5SMA automates the verification and eligibility determination for MAGI and non-MAGI populations, eliminating the vast majority of human error from the process. SMA uses shared eligibility service eliminating inaccuracy in application of rules across insurance affordability programs. Accuracy challenges still exist in the manual processing of documentation, but SMA reduces errors as much as possible through standard operating procedures.

Business Capability Quality: Utility or Value to Stakeholders

How satisfied are the stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information, negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3Automation of MAGI process and reliance on electronic verification improve stakeholder satisfaction to 80% or higher.
  4. LEVEL 4Use of shared eligibility service increases the efficiency, speed, and accuracy of the process, improving stakeholder satisfaction to 90% or higher.
  5. LEVEL 5Use of shared eligibility service that incorporates non-MAGI eligibility increases the efficiency, speed, and accuracy of the process, improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Eligibility and Enrollment Management BCM.pdf, pages 1-12.

Other Eligibility and Enrollment Management processes

Determine Provider EligibilityDisenroll MemberDisenroll ProviderEnroll MemberEnroll ProviderInquire Member EligibilityInquire Provider Information