The process for making a MAGI-based eligibility determination is largely the same for all insurance affordability programs. The Affordable Care Act requires a single, streamlined application, accompanied by a similar set of business rules and verification processes, and an adjudication work flow that is largely identical between Exchanges, Medicaid and CHIP programs.
It is expected that State agencies that receive Federal funds from CMS to establish State-based Exchanges and provide for Medicaid and CHIP expansions coordinate efforts to produce a shared eligibility service or system that relies on a shared IT infrastructure and as such, cost allocate this service.
A shared eligibility service is not the same as one system. We define an eligibility service as a set of IT functions that produce an eligibility determination based upon MAGI. The service incorporates an application, a set of verifications (for citizenship, income, residency, etc.) and business rules that together determine how much financial assistance a consumer should receive to acquire affordable health insurance.
While policies codified in final regulations allow legal authority for eligibility determinations to remain with state Medicaid agencies (for Medicaid) and Exchanges (for premium tax credits and cost-sharing reductions), the underlying business rules and processes are nearly identical, and should, to the maximum extent practical, rely upon a shared IT service(s) and infrastructure.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 46.1 KB) (PDF 46.1 KB)