CMS Proposes Rule for Eligibility Procedures for State Exchanges

The Centers for Medicare and Medicaid Services has issued a proposed rule governing eligibility procedures for obtaining health care coverage through state health insurance exchanges. The rule is one of three being published in coming days to implement provisions of the Affordable Care Act.

The eligibility proposed rule is available here and scheduled for publication on August 17. "The proposed eligibility process is designed to minimize opportunities for fraud and abuse, including the use of clear eligibility standards and processes that rely on data sources in an electronic environment," according to the rule.

CMS proposes to split the applicant verification process into two parts: verifying eligibility for enrollment in a qualified health plan and verifying eligibility for insurance affordability programs, such as advanced payment of tax credits. Verification will first rely on sources of electronic data that may include records of the Social Security Administration, Department of Homeland Security and the Internal Revenue Service, as well as other sources.

The same eligibility determination processes will be conducted regardless of the agency that initially receives an application for enrollment in a health plan. Exchanges must utilize a secure interface to exchange data with Medicaid, CHIP, and any state-established Basic Health Program operating in the service area.