CMS Issues Guidance On State Alternative Applications For Health Coverage


The Center for Consumer Information and Insurance Oversight (CCIIO) has issued guidance on alternative applications that state-based marketplaces, as well as certain Medicaid and Children’s Health Insurance Program (CHIP) agencies, may use in place of the model single, streamlined application for coverage that the Centers for Medicare and Medicaid Services (CMS) issued on April 30, 2013. The CCIIO has advised that state-based marketplaces, as well as the Medicaid and CHIP agencies within those states, may choose to use either the model application or develop their own alternative single, streamlined application that will have to be approved by the CMS. States using a federally-facilitated marketplace, however, may only use the model CMS application, available at Medicaid and CHIP agencies within states using a federal-facilitated marketplace may use alternative applications, but they must be able to accept and process the paper version of the model application if a coverage applicant submits it.

The requirements for alternative applications include the following:

• They must request information necessary for determining eligibility for coverage in a qualified health plan (QHP) and all insurance affordability programs.

• Only questions that are necessary for determining coverage eligibility in a QHP and all insurance affordability programs, including administration of these programs, may be asked.

• Burdens on applying households should be minimized. State-based marketplaces must provide two paths in applications so that individuals who opt out of financial assistance do not need to answer financial questions.

• States must rely first on available electronic data sources, such as the Federal Data Services Hub, and should request paper documentation only when electronic data is insufficient or inconsistent.

No approval required for some alterations. Some customizations that do not need formal approval from the CMS include the addition of state agency and program names and contact information, different colors, and logos that reflect appropriate branding for the state, elimination of questions irrelevant to a state’s eligibility rules, and, in certain instances, the inclusion of additional income or other verification data sources outside of those received from the Federal Data Services Hub. It also is acceptable to add privacy language to an application, if required by state law, and to change the placement and order of questions regarding contact information. If the state does not plan to send text messages to individuals, it is acceptable to remove the question about text messaging.

It also is generally acceptable to make the following modifications without first obtaining CMS approval: (1) a removal of questions when a state elects to address an issue post-eligibility; (2) a change in question order; (3) the addition of questions necessary in order to complete a modified adjusted gross income (MAGI)-based eligibility determination; and (4) making the application more “dynamic” to coordinate it with a state’s Medicaid eligibility categories.

CMS approval is required, however, for different implementations of the option to consider reasonably predictable future changes in income, different mechanisms for determining the existence of federal income tax filing requirements for dependents and children, different approaches to the timing of checking electronic data sources during the questioning process, and additional questions related to eligibility for Medicaid on a basis other than MAGI.

Alternative application submission and review. Medicaid and CHIP agencies will use the state plan amendment (SPA) process in order to have their alternative applications reviewed and approved. The CMS has stated that it will soon release SPA pages to assist states in indicating whether or not they will use the model application or an alternative application. States should submit a full copy, for the paper application, of the proposed alternative form along with any supplement or instructions related to MAGI-based determinations. For online applications, states should submit any or all of the following: a questionnaire similar in format to the model application online questionnaire, a packet of screenshots showing what a family completing an alternative application would see, and a flow chart show the logic necessary for applicants to move through sections and questions on the online application. States also must identify and describe key differences between the model application and the state’s alternative application.

To receive conditional approval of an alternative application, a state must attest that the application meets, or will meet by a certain date, all general principles described in this latest June 18, 2013, guidance and that the design of the application aligns with the proposed model. The state also must submit a proposed timeline for addressing any CMS recommendations.

For full approval of an alternative application, a state must modify its application based on CMS’ recommendations and submit evidence of the modifications.

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