Approaching the
Combined Application
Process under the ACA
Stacy Dean
Center on Budget and Policy Priorities
AASD Annual Conference
September 22, 2013
Our Plan for Today
1. Overview of Multi-Benefit Application
Landscape Today
2. Overview of Key CMS and FNS Guidance on
Multi-Benefit Applications
3. Presentations from Alaska, California and
New Mexico
4. Q & A
States with Joint SNAP/Medicaid
Applications (pre ACA)
19 States Have Multi-Benefit
Applications Approved for Day 1
4
Key CMS Requirements
• Must have a single, streamlined health-only
application as well
• Must be a pathway to all insurance
affordability programs
– There are some new questions that must be
included
– Some questions will likely have to be revised
• Questions for non-health programs can’t be a
barrier to a MAGI determination
• Approval process
5
Data Element Needs for Health Applications
MAC Collaboratives: Federal/state partnership to support high-performing state health insurance programs. Established by the Centers for
Medicare &Medicaid Services and coordinated by MathematicaPolicy Research, the Center for Health Care Strategies, and ManattHealth
Solutions. Visit http://www.Medicaid.gov.
6
Household Income
Ex: Required Change to an Old Question (Income)
Need to
estimate
Next
Year’s
Income
Idaho's Integrated Application
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Approval Process
• State plan amendment process
– CMS is offering TA
– Conditional approval option for 2014
• States must submit
– Analysis document identifying key differences
between alternative and model applications
– A copy of paper applications
– For online: flow chart, screen shots and/or
questionnaire (CMS request demo)
8
Use of Alternative Applications
• Information about States that are approved
will be made public with the “State’s Profile.”
• So far it appears that most states will have at
least one alternative application and very few
Medicaid agencies will use the HHS
applications.
9
Resources
• CMS resources
– Guidance:http://www.medicaid.gov/AffordableCareAct/Provisions/Downloads/Alternative
-App-Guidance-061813-508-comp.pdf
– Tools for multi-benefit applications: http://www.medicaid.gov/State-ResourceCenter/MAC-Learning-Collaboratives/Learning-Collaborative-State-Toolbox/State-ToolboxExpanding-Coverage.html
• Other resources:
– Coordinating Human Services Programs with Health Reform Implementation: A Toolkit for
State Agencies http://www.cbpp.org/files/6-6-12health.pdf
– Communicating in Plain Language, by Nicole Donnelly, Penny Lane, and Joan Winchester
at the Maximus Center for Health Literacy, February 2012,
http://files.www.enrollamerica.org/best-practices-institute/publications-andresources/2012/Communicating_with_Plain_Language.pdf
– Online Services for Key Low-Income Benefit Programs: What States Provide Online with
Respect to SNAP, TANF, Child Care Assistance, Medicaid, CHIP, and General Assistance,
Center on Budget and Policy Priorities,
http://www.cbpp.org/cms/index.cfm?fa=view&id=1414
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SNAP Application Requirements Remain
• Right to file an application without delay
– Ability to submit with just “name, address, signature”
– Minimal pre-registration process
• Location of expedited screening questions
• Recent FNS Guidance on online applications:
– SNAP Applications and the ACA
http://www.fns.usda.gov/sites/default/files/SNAP080213.pdf
– Online Application and Review Results
http://www.fns.usda.gov/snap/rules/Memo/2011/121710
.pdf
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SNAP Applications and the ACA
• States must notify FNS when existing
applications are modified or launched.
• FNS prepared an Online Application Checklist
for states to use to review their applications.
• FNS regions will review all applications for
compliance by September 2014.
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FNS Online Checklist
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Goals for a New Multi-Benefit Application
• Apply for all multiple
services with one
application
• Ensure those who are not
Medicaid eligible could be
easily determined for an
APTC
• Integrate the application
with automated eligibility
system and processes
• Meet compliance standards
for federal programs
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Issues for SNAP-Health Applications
Limited guidance
on multi-benefit
application rules
or approval
processes
• Examples?
• What’s the
turnaround?
• CMS/FNS
coordination?
Possible policy
conflicts
• “My account”
registration
requirements
• Accepting
incomplete
applications
• Authorized Rep
rules
Length and
complexity may
increase
Transition
issues vs. long
term
• Model health
applications are
long and complex
• SNAP can save
questions for the
interview
• Tight time frames
may necessitate
creative short term
solutions
• Over the long run,
applications will tie
into new integrated
eligibility systems
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Putting Together the Pieces: Keys to a Combined
Streamlined Application
AASD Conference
September 22-25, 2013
Horizontal Integration
–
–
–
The ACA requires the federal Secretary of HHS to develop health
information technology (HIT) interoperable and secure standards and
protocols that facilitate enrollment of individuals in federal and state health
AND human services programs. The law specifically requires these
standards to allow for the “ability to expand the enrollment system to
integrate new programs, rules, and functionalities, to operate at increased
volume, and to apply streamlined verification and eligibility processes to
other federal and state programs, as appropriate.”
What this means in California– By January 1, 2014, our eligibility
enrollment systems and policies must be aligned with Covered California
(CC) so that persons applying for health coverage (private, subsidized or
Medi-Cal) through CC or through County Welfare Departments can enroll
in health coverage, and our programs in a streamlined process.
Impact to SNAP/TANF – Applications, policies, and procedures must be
redesigned to facilitate enrollment for all programs.
Setting Goals and Facing Challenges





Integrating program questions to avoid
duplication and a LONG application
Sequencing questions in a logical order
Making it clear to clients what questions to
answer for what programs
Ensuring only one signature is required
How to handle MAGI and Non MAGI questions
~~~~~~~~~~~~
Development Process
We started with our SNAP app as the
building blocks as it is key
~~~~~~~~~~~~
We worked with stakeholders to develop
SNAP app based on review of applications
from every other state. Finalized in April.
“Imitation is the sincerest form of flattery”
Single Streamlined Application



CMS released the Single Streamlined
Application (SSApp) in May 2013 – our
computer systems needed data elements
immediately to begin programming.
A few people (1 TANF, 2 SNAP) worked
feverishly to put together a draft that
added required elements from TANF and
SSApp into the SNAP application.
Once draft was assembled in June,
walked through with CMS, FNS,
counties, health exchange and
programming staff.
Combined Streamlined Application




We quickly incorporated edits and provided feedback
to all. Highly encourage early involvement with CMS.
The application was finalized in July and work began
on translations and printing.
Paper applications are available in October.
Final application language is now being programmed
into systems to be available in January for online
applications.
Successes

We developed grids for listing of adults and child applicants that
incorporate the key questions for program so there are not repetitive
pages to complete for each person. It makes it a lot easier visually to
see household composition.

This approach also lent itself to a more logical flow of questions, e.g.,
first income, then deductions for every member of the household.

Using symbols, we made is visually very clear for those using paper
applications which questions they need to answer depending on the
program.

We achieved a one signature required form that integrated many other
forms into one document.
Successes
Successes
Next Steps

Despite our best efforts to “streamline” a multi-program application is
longer than one would hope.

While OK for initial application, one next step is develop a much leaner
application for renewals.

Additionally, since required to move very quickly to have in place,
there will be future revisions as people work with it.

Other stakeholders, like advocates, were assured they would have
opportunities to tweak in the future. There was less resistance as they
had all been involved in the work to develop the SNAP app.
Making it Work
Developing A Combined
Application for Alaska
Goals
Continue to use one application for all programs.
Complete revisions by October 1.
Continue to meet federal requirements for all programs.
Make application less burdensome for the client.
Gather as much information as possible so we don’t
have to pend or send supplemental forms.
Include all post eligibility forms (absent parent form,
employer statement, voter registration)
Timeline
April
Established
Work Team
May
Initial
Revision
June
• Edited for
Content
• Initial CMS
Review
July
Revised
with CMS
Comments
August
• FNS Review
• Dept of Law
Review
• Field review
• Updated
application
• Formatting
September
•Final Policy
Review
•CMS Review
•Final
Formatting
•Printer
Process
 Surveyed staff and applicants about what they liked and
didn’t like about our current application
 Paper application designed by new policy staff

Reviewed federal regulation – which suggestions from
survey could we do?

Once we had the FFM application, used that
format/questions to design our paper application
 Online application designed by Deloitte with input from
agency staff.
 CMS reviewed both online and paper application.
reviewed paper application.
FNS
Successes
 Modernization
 Online Application
 Communicate with applicants and recipients via email
 CMS approved our application more quickly than we
expected.
 Questions for other Public Assistance programs were not
changed.
 There’s more room for people to provide information
because each individual has their own page.
 Less chance the case will be pended because have more
information.
Income Information
Appendices
Challenges
Online Application
Last minute review of online application by CMS.
Will be for ACA related Medicaid only until 7/15.
Will not auto populate new system.
Paper Application
Coordinating edits to paper application long distance.
Perceived as being too long but it went from 24 pages to 27.
Staffing struggles
Final regulations and feedback from CMS slow.
Different visions between federal programs and internally.
Not allowed to ask questions that will streamline the
process (such as absent parent information).
FFM application can’t be used to protect start date for other
programs.
Additional Questions
Required by FNS
Next Steps
 Work towards designing an online application for all
programs.
 Review applications from other states to get ideas for
improvement.
 Get feedback from the field and applicants as they use
the applications.
 Change and change again
Bringing It all Together
New Mexico’s Streamlined Application for Assistance

Utilize one application to for all programs.

Ensure application is ready on October 1, 2013.

Ensure compliance with all Federal Programs
(CMS, FNS and Voter Registration).

Ensure compliance with current Legal Settlement
Agreements.


Ensure proper sequencing of questions meeting
all of the federal mandates for “on or near the
front of the application.”
Make it clear to applicants which questions to
answer for each program.
Internal Stakeholders were brought together in
September 2012. The included representation
from the following:
Office of the Secretary (OOS)
Medical Assistance Division (MAD)
Income Support Division (ISD)
Information Technology Division (ITD)






MAD staff incorporated the ACA requirements (known at the
time) into the existing combined application.
ISD staff reviewed to ensure that application met the Federal
requirements.
During review by Office of General Counsel, met with our IT
contractor Deloitte to map the Streamlined Application with the
Online Application on the new Your Eligibility System New
Mexico (YES-NM) and ASPEN
Utilized FFM application to re-format and add questions to the
design.
CMS reviewed paper application first. They are currently
reviewing the Online Application.
Received public comment from our Settlement Agreement
Plaintiff’s.

Modernization
Online Application (YES-NM)
New Eligibility System (ASPEN)


Updated existing application for other
Public Assistance programs that were
not previously included.
CMS comments were not extensive
mostly suggestions or clarifications.
Online Application
Last minute review of online application by CMS –
Sent on 9/19.
Mapping of the paper application with YES-NM
and ASPEN ensuring the capture of the data
needed by the Marketplace.
Paper Application
Coordinating edits from many all stakeholders.
Perceived as being too long but it went from 12 to
19 pages.
Late receipt of Final regulations.
Ensuring clarification of different
requirements between federal programs when
gathering information such as income.
FFM application can’t be used to protect start
date for other programs.
The Finished Product
Income Information
Continue to refine the online
application to include all of the data
required by the FFM.
Review applications from other states
to get ideas for improvement.
Vida Tapia-Sanchez
Acting ISD Deputy Director of Field Operations
505-827-1300
Vida.Tapia-Sanchez@state.nm.us.