MAGI Eligibility RulesMESC 2012Boston, MA August 19-23, 2012Proprietary and Confidential                                1
The Challenge:        For states, meeting the new eligibility rules of the ACA provides        significant challenges:    ...
Federal Mandate: “Seamless Eligibility Determination”                           Proprietary and Confidential              ...
State Flexibility: Medicaid Expansion Options                           Proprietary and Confidential                      ...
eSante-Rules Overview  – Business Logic Integration Platform – Business rules,    workflow, and events  – Based on Open So...
How Cognosante can help: eSante-Rules Solution BenefitsCognosante eSante-Rules provides:   –   Single, stream-lined eligib...
Proprietary and Confidential                               7
eSante-Rules Demo: Eligibility Verification and Determination                           Proprietary and Confidential      ...
Meet the Hood Family on January 7, 2014         Age: 39                                       Age: 37                     ...
eSante-Rules               https://app02.smartstream.cognosante.com/               guvnor-5.4.0.Final-tomcat-             ...
Hood Family Results: 92% FPL (2012 rates)     Rule        Mark       Marilyn            Alicia                 Alex     Ar...
Having a rules engine isn’t enough• Subject matter expertise:   – Understand:        • the federal regulations and require...
Expertise + Tools = The Right ImplementationIt’s a snap!Contact:Cathy.Graeff@Cognosante.comHIX Practice LeadBruce.Dunham@C...
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Cognosante MAGI Eligibility Rules

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Cognosante presents its solutions and expertise for helping states meet the new eligibility rules under the Patient Protection and Affordable Care Act. Cognosante's eSante solution, based on open-source technology, helps states determine their MAGI category within Medicaid eligibility and allows states to integrate rules for their existing rules engines.

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  • States face Major challenges. Significant changes to current eligibility processes Yet, the clock keeps tickingMajor revisions to current eligibility systems and rulesIntegration with Exchanges Major investments in state resources, including staff time that already have full time day jobsDespite the challengesSince the SCOTUS: The intent of MAGI is to provide administrative simplification for Medicaid Eligibility determination Standardizes much of the income computation Provides for simplification of Medicaid categories of eligibilityIncreased state based flexibility Questions still abound Discrepancies still remain between HHS and IRS rules “to expand or not to expand?” If the former, how do states make this affordable in 2017? Options for pregnant woman and children How do we support Does the “no wrong door still exist?
  • Seamless eligibility processing is the cornerstone to the ExchangeNew Exchanges must evaluate eligibility applications and provide “seamless eligibility determination” across QHPs, APTCs, Medicaid/CHIP A myriad of questions, options for states, including different options for specific population groups1. Full Medicaid benefits. 2. Pregnancy-related benefits. 3. Optional Medicaid group. States may include pregnant women in the new optional Medicaid group for those with incomes above 133 percent FPL. 4. Basic Health Program. States may include pregnant women in the state’s Basic Health Program (BHP), if any, for those with incomes up to 200 percent FPL. 5. Subsidized exchange coverage. Pregnant women with incomes above Medicaid (or BHP) levels could be left to access the exchange to purchase private coverage subsidized by the appropriate APTC/CSR. 6. Medically needy program. States may maintain a Medicaid medically needy program for pregnant women who are ineligible for Medicaid and unable to afford other coverage; this program would use non-MAGI income methodology. 7. CHIP coverage option for pregnant women
  • States need “shovel ready tools” and expertise to help implement new options and policiesCognosante provides technical capabilities and subject matter expertise to implement eligibility changes- provides flexible, open source, rules engine complete with a full base of eligibility rules to support no wrong door for QHPs, APTC, and MAGI- Flexibility and modular technology to integrate with a variety of Exchange solutions, rules engines- and lastly, the staff with the experience, knowledge, and understanding of Medicaid eligibility policy and rules to help states implement Medicaid expansion options in a timely fashion- The result for states = “Speed to value”Reduced implementation timeReduced impact to state staffReduced implementation costs
  • Citizenship, Residency, Incarceration, TribalFairly simple rules – are you or aren’t you? Big question: Where to get the information?Flexibility in source informationCitizenship – only one source allowed (SAVE)Residency – State or Federal?Incarceration – State or Federal?Tribal – State or Federal?Household Size Based on prior year tax filingWhat about Cousin Itt? What about Thing?What if Gomez was not a qualified LPR?Household IncomeWhat is countable vs not-countable? Child Support, Unemployment InsuranceIRC-36.B vs. 42CFR 435.603(e)Data Source – State or Federal?Last year’s taxable income or point in time?How to handle non-MAGI populations?FPLDifferences between CMS and HHS rangesWhat if you don’t want to expand your Medicaid populations?Data ExchangeData Validation of the applicationWhat is passed from HIX to your Eligibility Determination System?
  • Intro to storyOverview of Drools- Knowledge base repository--Stores complete library of eligibility rules for determining eligibility for QHPs, APTCs/CSR, and MAGI Medicaid--Provides capabilities for workflow
  • 48 Contiguous States and the District of Columbia (2012)% Gross Yearly Income Family Size 25% 50% 75% 81% 100% 133% 175% 200% 250% 300% 1 $2,793 $5,585 $8,378 $9,048 $11,170 $14,856 $19,548 $22,340 $27,925 $33,510 2 $3,783 $7,565 $11,348 $12,255 $15,130 $20,123 $26,478 $30,260 $37,825 $45,390 3 $4,773 $9,545 $14,318 $15,463 $19,090 $25,390 $33,408 $38,180 $47,725 $57,270 4 $5,763 $11,525 $17,288 $18,671 $23,050 $30,657 $40,338 $46,100 $57,625 $69,150 5 $6,753 $13,505 $20,258 $21,878 $27,010 $35,923 $47,268 $54,020 $67,525 $81,030 6 $7,743 $15,485 $23,228 $25,086 $30,970 $41,190 $54,198 $61,940 $77,425 $92,910 7 $8,733 $17,465 $26,198 $28,293 $34,930 $46,457 $61,128 $69,860 $87,325 $104,790 8 $9,723 $19,445 $29,168 $31,501 $38,890 $51,724 $68,058 $77,780 $97,225 $116,670
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  • Cognosante MAGI Eligibility Rules

    1. 1. MAGI Eligibility RulesMESC 2012Boston, MA August 19-23, 2012Proprietary and Confidential 1
    2. 2. The Challenge: For states, meeting the new eligibility rules of the ACA provides significant challenges: • Conversion to MAGI • Conflicting Regulations • New State Options and Flexibility for Medicaid Expansion Requires investment in updating systems, operations • State Staff Time = $$$ • DDI = $$$ • Short Implementation Timeframe = $$$ Proprietary and Confidential 2
    3. 3. Federal Mandate: “Seamless Eligibility Determination” Proprietary and Confidential 3
    4. 4. State Flexibility: Medicaid Expansion Options Proprietary and Confidential 4
    5. 5. eSante-Rules Overview – Business Logic Integration Platform – Business rules, workflow, and events – Based on Open Source technology – Full set of Eligibility rules for determining QHP, APTC/CSR, and Medicaid eligibility – Ability to determine MAGI Category within Medicaid Eligibility – Capability to integrate rules with your state’s existing rules engines – Use for HIX or IES Proprietary and Confidential 5
    6. 6. How Cognosante can help: eSante-Rules Solution BenefitsCognosante eSante-Rules provides: – Single, stream-lined eligibility determination – Supports “No Wrong Door” – Flexible approach – Supports State Partnership Exchange (SPE) or State Based Exchange (SBE) modelsThe result for States: “Speed to value” – Reduced implementation time – Reduced impact to state staff – Reduced implementation costs Proprietary and Confidential 6
    7. 7. Proprietary and Confidential 7
    8. 8. eSante-Rules Demo: Eligibility Verification and Determination Proprietary and Confidential 8
    9. 9. Meet the Hood Family on January 7, 2014 Age: 39 Age: 37 Age: 40 Citizenship: LPR Citizenship: Yes Citizenship: Yes Residency: TN Residency: TN Residency: Yes Income: $100 Income: $2,000 Income: $4,000 Income Type: UI Income Type: Wages Income Type: Wages Income Frequency: Weekly Income Frequency: Monthly Income Frequency: MonthlyAge: 3 Age: 6 Age: 1 Age: 11Citizenship: Yes Citizenship: Yes Citizenship: Yes Citizenship: Yes Residency: TNResidency: TN Residency: TN Residency: TN Income: $200Income: No Income: No Income: No Income Type: Child Support Income Frequency: Monthly Proprietary and Confidential 9
    10. 10. eSante-Rules https://app02.smartstream.cognosante.com/ guvnor-5.4.0.Final-tomcat- 6.0/org.drools.guvnor.Guvnor/Guvnor.jsp? Proprietary and Confidential 10
    11. 11. Hood Family Results: 92% FPL (2012 rates) Rule Mark Marilyn Alicia Alex Arthur GrantCitizen LPR >5 Citizen Citizen Citizen Citizen CitizenResidency √ √ √ √ √ √Incarcerated No No No No No NoTribal No No No No No NoIncluded in HH √ √ √ √ √ √MonthlyCounted Income $400 $2000 $0 $0 $0 $0Household Size Total Annual Income Parent Medicaid Child Medicaid 6 $28,800 2 4 Proprietary and Confidential 11
    12. 12. Having a rules engine isn’t enough• Subject matter expertise: – Understand: • the federal regulations and requirements, • State specific Medicaid Eligibility policies • State Goals for Medicaid Expansion – 25+ years experience with Medicaid eligibility – Experience performing requirements analysis, rules verification for numerous state agencies – Healthcare Reform Subject Matter Expertise• Right Technology tools and partners – Rules engine – Ability to integrate with YOUR Exchange solution – MAGI Rules pre-loaded – Configurable for state specific programs and policy decisions – Easy User Interface, Test Rule changes before implementation Proprietary and Confidential 12
    13. 13. Expertise + Tools = The Right ImplementationIt’s a snap!Contact:Cathy.Graeff@Cognosante.comHIX Practice LeadBruce.Dunham@Cognosante.comEligibility Practice Lead Proprietary and Confidential

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