The Health Insurance Exchange, the Medicaid Program, and the Apportionment of Responsibility for Determining Eligibility and Effectuating Enrollment in New Jersey

Abstract

The Affordable Care Act and its implementing regulations embody a “no wrong door” philosophy for determining individuals’ eligibility for, and enrolling them in, federal, state, and local public health insurance programs, including premium subsidies, cost-sharing reductions, Medicaid, the Basic Health Program, if a state chooses to establish one, and the Children’s Health Insurance Program. The Act requires that states build online systems that will enable them to make eligibility determinations in real time, that they use a single, streamlined application for all programs, and that they make full use of data-driven electronic verification of the information applicants provide.

This brief provides an overview of the Act’s provisions regarding eligibility determinations and renewals, with a particular focus on (1) the degree of coordination that will be required between New Jersey’s Division of Medical Assistance and Health Services (DMAHS) and its health insurance Exchange and (2) the options set forth in the Act for apportioning responsibility for the eligibility determination and enrollment functions between DMAHS and a state-based exchange, should the State choose to establish one. The brief then discusses New Jersey eligibility and enrollment law, policy, and practice and sets forth the key decision points facing the state as it strives to create a streamlined and seamless system to support swift and accurate eligibility determinations and enrollment into coverage.