Using Express Lane Principles to Enroll Individuals in Health Insurance Programs

Express lane principles, the automated use by one agency or program of data gathered and/or findings made by another, will be used by states as 2014 approaches to enroll and retain individuals in health coverage programs. Beginning in 2014, under the Affordable Care Act (ACA), millions of adults and children who are currently uninsured will gain eligibility and enroll in Medicaid, the Children’s Health Insurance Program (CHIP), and other coverage through health insurance Exchanges. Many of these individuals participate in other need-based public programs for which they have already provided income and other data to establish eligibility. The ACA includes provisions for states to leverage existing data sources as much as possible to develop simple and streamlined processes for determining eligibility for Medicaid, CHIP, and subsidies for Exchange coverage. The Henry J. Kaiser Family Foundation recently released a Focus on Health Reform brief titled “Explaining Health Reform: Uses of Express Lane Strategies to Promote Participation in Coverage.” According to the brief, use of express lane data sharing will facilitate states’ implementation of the coverage expansion required by the ACA by creating “the most consumer-friendly user experience possible for individuals and families.” The investment of public dollars will be “optimized…in modernized, efficient enrollment systems that support ACA’s vision,” the brief continued. Specific examples of the use of express lane principles include: (1) automatic transfer to Medicaid of the 700,000 children in CHIP who are between 100% and 133% of the federal poverty level; (2) streamlined enrollment for parents of children already enrolled in Medicaid and CHIP and for uninsured children and adults who participate in the Supplemental Nutrition Assistance Program and/or other public programs; (3) pre-enrollment individuals who are currently in limited coverage; (4) identification and outreach to hard-to-reach individuals who are enrolled in other public programs; and (5) routine renewal of coverage and facilitated transitions between programs. Express Lane Eligibility (ELE), a component of express lane principles, refers to an optional authority provided to states in section 203 of the CHIP Reauthorization Act of 2009 that allows state Medicaid and CHIP agencies to rely on data from an Express Lane agency (or agencies) to simplify the process for determining eligibility and facilitating enrollment of children in Medicaid and CHIP. ELE requires use of modified adjusted gross income to determine income eligibility for health subsidy programs. Statutory ELE authority is available only to determine children’s eligibility for Medicaid and CHIP; states will need approval from the Centers for Medicare & Medicaid Services (CMS) prior to using statutory ELE to process eligibility for subsidized health coverage for adults, the Kaiser brief noted. The brief continued by outlining federal policies and funding opportunities available to support states’ use of express lane principles. Since the enactment of ACA, there have been efforts at the federal level to develop policies, procedures, and systems to support interoperability (the bidirectional exchange of information between agency systems) consistent with express lane principles, including: (1) funding guidelines that promote data sharing; (2) calls for greater collaboration, efficiency, and effectiveness; (3) new standards and protocols governing enrollment processes; and (4) a growing emphasis on creating a positive experience for the consumer. Guidelines for creating a positive experience for the consumer are included in documents by federal agencies as part of the implementation of ACA; one such document is the CMS Guidance for Exchange and Medicaid Information Technology (IT) Systems 2.0, establishing “an expectation for collaborative IT development that ensures a first-class consumer experience,” according to the Kaiser brief. The CMS document includes an expectation that systems developed or enhanced as part of Exchange development will “ensure seamless coordination between the Exchange, Medicaid, and CHIP, and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.” Other guidelines in development include the National Information Exchange Model to support consistent, efficient, and transparent exchange of data between federal programs. In conclusion, the authors of the Kaiser brief said, “Americans’ health and welfare is advanced when it is simple for individuals and families to enroll in the programs or services they need. The technologic developments of the past decade make such simplification possible in unprecedented ways, and ACA provides states with the policy guidance and financial incentives to build systems that capitalize in information technology, delivering a first-class user experience. States can use express lane principles in designing these systems, paving the way for Americans to participate in health coverage as ACA envisions, and improving government efficiency and effectiveness in the process.”