Eligibility and Enrollment

A system or subsystem that assigns accurate eligibility categories for all applicable eligibility groups by receiving, ingesting, and processing: Applications, changes of circumstance, renewal forms, and any supporting documentation requested by the state (including telephonic signatures) from individuals.

CMS-Required Outcomes (27)

Ref	Outcome	Sources
EE1 Application	The eligibility system receives, ingests, and processes the single-streamlined applications, change of circumstances, renewal forms, and any supporting documentation requested by the state (including telephonic signatures) from individuals, for all Medicaid eligibility groups and CHIP through online via multiple browsers, mail (paper), phone, and in-person (e.g., via kiosk) applications to support eligibility determination for all Insurance Affordability Programs (Federal Health Insurance Exchange), state Medicaid or CHIP, State-Based Marketplace (SBM), Basic Health Program (BHP).	42 CFR 435.907 42 CFR 435.916 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE2 Application	Individuals experience a user-friendly, dynamic, online application, such that subsequent questions are based on prior answers.	42 CFR 435.907 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE3 Automatic Enrollment	Individuals eligible for automatic Medicaid eligibility are promptly enrolled (e.g., SSI recipients in 1634 states, individuals receiving a mandatory state supplement under a federally- or state-administered program, individuals receiving an optional State supplement per 42 CFR 435.230 , and deemed newborns). (Automatic enrollment in Guam, Puerto Rico, and the U.S. Virgin Islands is required only for individuals receiving cash assistance under a state plan for OAA, AFDC, AB, APTD, or AABD, and deemed newborns.)	42 CFR 435.117 42 CFR 435.909 42 CFR 436.909 42 CFR 436.124For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE4 Income Methodologies	The state correctly calculate income and household composition based on Modified Adjusted Gross Income (MAGI) and non-MAGI methodologies at application and renewal. Example business rules include subtracting 5 percentage points off FPL for applicable family size	42 CFR 435.601 42 CFR 435.603 42 CFR 435.811-814 42 CFR 436.601 42 CFR 436.811-814 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE5 Electronic Verification	The eligibility system uses automated interfaces with electronic data sources to enable real-time or near real-time, no manual touch eligibility determinations. The data sources include (but are not limited to) SSA and the Department of Homeland Security (DHS) (directly or via the Federal Data Services Hub (FDSH)), state quarterly wage data, data from financial institutions for asset verification, Renewal and Redetermination Verification service through the FDSH, Public Assistance Reporting Information System (PARIS) to verify Medicaid coverage in other states.	42 CFR 435.940-965 42 CFR 435.945(d)42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:For Puerto Rico:- Consolidated Appropriations Act of 2023, Section 5101 (requiring an Asset Verification System to be implemented by 2026)
EE6 Timely Determinations	Individuals who apply for Medicaid based on disability receive an eligibility determination within 90 days and all other applicants receive an eligibility determination within 45 days.	42 CFR 435.911-912 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE7 Reasonable Opportunity Period	Individuals are enrolled for up to 90 days if pending verification of citizenship or immigration status.	42 CFR 435.407 42 CFR 435.956 42 CFR 436.407 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE8 SSN Verification	Individuals are enrolled pending verification of SSN.	42 CFR 435.910 42 CFR 435.956(d)42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE9 Notices	Individuals receive system-generated timely automated (versus manual) eligibility notices and request for additional information for eligibility determination, as necessary.	42 CFR 431.210-214 42 CFR 435.917-918 42 CFR 436.901For all states, District of Columbia, and territories:For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE10 Notices	Individuals receive electronic notices and alerts as applicable via their preferred mode of communication (e.g., email, text that notice is available in online account).	42 CFR 431.210-214 42 CFR 435.917-918 42 CFR 436.901For all states, District of Columbia, and territories:For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE11 Enrollment	Following an eligibility determination, the system promptly sends the beneficiary information to MMIS to complete enrollment into the appropriate delivery system (e.g., FFS, managed care).	42 CFR 435.914 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE12 Presumptive Eligibility Applications	The system receives Presumptive Eligibility (PE) applications from all approved entities in an automated manner and facilitates eligibility termination if no full Medicaid application is received by the end of the month following the month of PE determination.	42 CFR 435.1110For states, District of Columbia, Northern Mariana Islands, and American Samoa:
EE13 Annual Renewals	The system uses electronic data sources to confirm eligibility, wherever possible, to facilitate ex-parte renewals.	42 CFR 435.916 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE14 Annual Renewals	If ex-parte renewal cannot be completed, the system can automatically generate pre-populated renewal forms and distribute those forms via individuals' preferred communication mode.	42 CFR 435.916 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE15 Eligibility Category	The system applies an automated eligibility hierarchy that places an individual in the most advantageous group for which they are eligible at initial application and renewal.	42 CFR 435.404 42 CFR 436.404For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE16 Eligibility Category	The system uses automated business rules to assign accurate eligibility categories for all the mandatory and relevant optional eligibility groups at initial application and renewal. Example business rules include: · Correct identification of individuals age 19-64 at or below 133 percent FPL (VIII group) · Correct alignment of eligibility categories to FMAP rate	42 CFR 435.404 42 CFR 436.404For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE17 Incarcerated individuals	Incarcerated individuals receive timely access to inpatient services and receive a timely and accurate eligibility determination upon release.	42 CFR 435.1009 42 CFR 436.1005For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE18 Emergency Medicaid	Individuals whose coverage is limited to emergency services due to immigration status receive timely and accurate eligibility determination.	42 CFR 440.255 42 CFR 435.139 42 CFR 436.128For all states, District of Columbia, and territories:For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE19 Retroactive Eligibility	Individuals receive timely and accurate determinations of eligibility for the three months prior to the date of application if the individual would have been eligible and received Medicaid covered services.	42 CFR 435.915 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE20 Effective Date of Eligibility	Individuals are promptly enrolled with the accurate effective date of eligibility in accordance with the approved State Plan.	42 CFR 435.915 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE21 Multi-Benefit Application	In states that have an integrated eligibility system with human services programs, the system is able to pend application for one program without having to do so for Medicaid or CHIP programs, if needed.	For all states, District of Columbia, and territories:- June 18, 2013, CMS Guidance on State Alternative Applications for Health Coverage
EE22 Integration with Other Programs	The state maintains a coordinated eligibility and enrollment process with all insurance affordability programs by supporting bi-directional data-sharing for application-related data and adjudication status with all relevant insurance affordability programs (FFE, CHIP, SBE if applicable, BHP if applicable).	42 CFR 435.1200For states, District of Columbia, Northern Mariana Islands, and American Samoa:
EE23 Account Transfers (for FFE Determination States)	Account Transfer information for individuals applying at the FFE from a determination state is automatically ingested and the state promptly enrolls individuals determined eligible by the FFE.	42 CFR 435.1200For states, District of Columbia, Northern Mariana Islands, and American Samoa:
EE24 Account Transfers (for FFE Assessment States)	Account Transfer information for individuals applying at the FFE from an assessment state is automatically ingested and the state conducts only the remaining verifications necessary to complete the determination process for individuals assessed as potential eligible by the FFE.	42 CFR 435.1200For states, District of Columbia, Northern Mariana Islands, and American Samoa:
EE25 Minimum Essential Coverage (MEC) Check	The system receives and responds to requests from the FFE in real-time to confirm whether an individual applying for coverage through the FFE currently has Minimum Essential Coverage through Medicaid or CHIP.	42 CFR 435.1200For states, District of Columbia, Northern Mariana Islands, and American Samoa:
EE26 Accessibility	Persons with disabilities or with Limited English Proficiency (LEP) can submit a single streamlined application with any necessary assistance (e.g., TTY for the hearing impaired for phone applications, and language assistance for persons with LEP).	42 CFR 435.905 42 CFR 435.908 42 CFR 436.901For states, District of Columbia, Northern Mariana Islands, and American Samoa:For Guam, Puerto Rico, and the Virgin Islands:
EE27 Appeals	Beneficiaries and applicants can submit an appeal against an adverse action via multiple channels (e.g., online, phone, mail, in person) and the status and adjudication of an appeal can easily be accessed by necessary state staff and appellants.	42 CFR 431.221For all states, District of Columbia, and territories: