ACA Eligibility Changes: Program Integrity Issues

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March 2014

The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) requires all states to simplify the Medicaid and State Children’s Health Insurance (CHIP) eligibility determination process for children, parents, pregnant women, and non-disabled adults under age 65. At the same time, states must continue to operate legacy systems to determine eligibility on the basis of age or disability. A no-wrong-door policy requires states to share eligibility information among Medicaid, the State Children’s Health Insurance Program (CHIP), and the exchanges, since some people who apply for premium subsidies have income low enough to qualify for Medicaid or CHIP in their states.

Chapter 4 of MACPAC’s March 2014 report reviews these new administrative changes, along with new strategies the Centers for Medicare & Medicaid Services are pursuing to help states ensure the accuracy of eligibility decisions and strengthen program integrity safeguards. Read more about efforts to strengthen Medicaid and CHIP program integrity under the ACA.

Publication Type: Reports to Congress

From: March 2014 Report to the Congress on Medicaid and CHIP

Tags: eligibility, eligibility determination, information technology, program integrity, waste/fraud/abuse