Eligibility and Enrollment (E&E)
How this system supports the Medicaid Program
A system or subsystem that assigns accurate eligibility categories for all applicable eligibility groups by receiving, ingesting, and processing: Applications, changes of circumstance, renewal forms, and any supporting documentation requested by the state (including telephonic signatures) from individuals.
CMS-Required Outcomes
Each CMS-Required outcome is based on statutory or regulatory requirements. CMS-Required Outcomes and Metrics are used to demonstrate that a system is compliant with the applicable federal regulations which pertain to that specific system or module. CMS-Required outcomes form the baseline for system/module functionality, which must continue to receive enhanced federal funding for operations.
| Reference # | CMS Required Outcomes | Default Metrics | Regulatory Sources |
|---|---|---|---|
| EE1 Application | The eligibility system receives, ingests, and processes the single-streamlined applications, change of circumstances, renewal forms, and any supporting documentation requested by the state (including telephonic signatures) from individuals, for all Medicaid eligibility groups and CHIP through online via multiple browsers, mail (paper), phone, and in-person (e.g., via kiosk) applications to support eligibility determination for all Insurance Affordability Programs (Federal Health Insurance Exchange), state Medicaid or CHIP, State-Based Marketplace (SBM), Basic Health Program (BHP). |
- Number/Percentage of applications (Medicaid only vs multi-benefit, when applicable) submitted through each modality (use Performance Indicator Data #5 'Number of Applications Received' submitted to CMS).
- Percentage of change in circumstances reported through each modality. - Percentage of supporting documents/information submitted through each modality. - Percentage of renewal documents submitted through each modality |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.907 - 42 CFR 435.916 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE2 Application | Individuals experience a user-friendly, dynamic, online application, such that subsequent questions are based on prior answers. |
- Average time it takes to complete an online application.
- User surveys - Abandonment rate of online applications - Outcome attestation of dynamic application skip logic |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.907 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE3 Automatic Enrollment | Individuals eligible for automatic Medicaid eligibility are promptly enrolled (e.g., SSI recipients in 1634 states, individuals receiving a mandatory state supplement under a federally- or state-administered program, individuals receiving an optional State supplement per 42 CFR 435.230 , and deemed newborns). (Automatic enrollment in Guam, Puerto Rico, and the U.S. Virgin Islands is required only for individuals receiving cash assistance under a state plan for OAA, AFDC, AB, APTD, or AABD, and deemed newborns.) |
- Percentage of individuals receiving SSI automatically eligible (1634 states only)
- Percentage of deemed newborns automatically eligible |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.117 - 42 CFR 435.909 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.909 - 42 CFR 436.124 |
| EE4 Income Methodologies | The state correctly calculate income and household composition based on Modified Adjusted Gross Income (MAGI) and non-MAGI methodologies at application and renewal. Example business rules include subtracting 5 percentage points off FPL for applicable family size |
- Most recent PERM results
- Description/reports of internal quality assurance processes |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.601 - 42 CFR 435.603 - 42 CFR 435.811-814 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.601 - 42 CFR 436.811-814 - 42 CFR 436.901 |
| EE5 Electronic Verification | The eligibility system uses automated interfaces with electronic data sources to enable real-time or near real-time, no manual touch eligibility determinations. The data sources include (but are not limited to) SSA and the Department of Homeland Security (DHS) (directly or via the Federal Data Services Hub (FDSH)), state quarterly wage data, data from financial institutions for asset verification, Renewal and Redetermination Verification service through the FDSH, Public Assistance Reporting Information System (PARIS) to verify Medicaid coverage in other states. |
- Number/percentage of individuals whose determinations were entirely automated
- Percentage of determinations that required a request for additional documentation from the applicant. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.940-965 - 42 CFR 435.945(d) For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 For Puerto Rico: - Consolidated Appropriations Act of 2023, Section 5101 (requiring an Asset Verification System to be implemented by 2026) |
| EE6 Timely Determinations | Individuals who apply for Medicaid based on disability receive an eligibility determination within 90 days and all other applicants receive an eligibility determination within 45 days. |
- Percentage of determinations (individuals) whose eligibility is based on non-MAGI methodologies which took less than or equal to 90 days (use Performance Indicator Data #12 'Processing Time for Determinations' submitted to CMS)
- Percentage of determinations (individuals) whose eligibility is based on MAGI methodologies which took less than or equal to 45 days (use Performance Indicator Data #12 'Processing Time for Determinations' submitted to CMS) - Percentage of determinations (individuals) whose eligibility is based on MAGI methodologies which took less than or equal to 45 days (use Performance Indicator Data #12 'Processing Time for Determinations' submitted to CMS) - Number of undetermined MAGI related applications (individuals) that are greater than 45 days from when they were received. - Number of undetermined non-MAGI related applications (individuals) that are greater than 90 days from when they were received. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.911-912 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE7 Reasonable Opportunity Period | Individuals are enrolled for up to 90 days if pending verification of citizenship or immigration status. |
- Number of individuals enrolled during a ROP period.
- Number of people who remained enrolled at the end of the ROP. - Number of people disenrolled at the end of the ROP for failure to verify citizenship or immigration status. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.407 - 42 CFR 435.956 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.407 - 42 CFR 436.901 |
| EE8 SSN Verification | Individuals are enrolled pending verification of SSN. |
- Number of individuals enrolled pending verification of SSN
- Number of people who remained enrolled upon verification of SSN - Number of people disenrolled for failure to verify SSN |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.910 - 42 CFR 435.956(d) For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE9 Notices | Individuals receive system-generated timely automated (versus manual) eligibility notices and request for additional information for eligibility determination, as necessary. |
- Percentage of notices automatically generated and sent
- Types of notices that are automated. - Types of notices that are manually generally. - Percentage of terminations due to lack of response to a notice |
For all states, District of Columbia, and territories:
- 42 CFR 431.210-214 For states, District of Columbia, Northern Mariana Islands, and American Samoa: - 42 CFR 435.917-918 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE10 Notices | Individuals receive electronic notices and alerts as applicable via their preferred mode of communication (e.g., email, text that notice is available in online account). | - Outcome attestation of ability for applicants to receive notifications in their preferred mode of communication. |
For all states, District of Columbia, and territories:
- 42 CFR 431.210-214 For states, District of Columbia, Northern Mariana Islands, and American Samoa: - 42 CFR 435.917-918 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE11 Enrollment | Following an eligibility determination, the system promptly sends the beneficiary information to MMIS to complete enrollment into the appropriate delivery system (e.g., FFS, managed care). |
- Percentage of automated transmissions to the MMIS.
- Percentage of transmissions to MMIS that require manual intervention or exceptions. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.914 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE12 Presumptive Eligibility Applications | The system receives Presumptive Eligibility (PE) applications from all approved entities in an automated manner and facilitates eligibility termination if no full Medicaid application is received by the end of the month following the month of PE determination. |
- Number of PE applications received.
- Percentage of individuals disenrolled at the end of the PE period for failure to file a full application. - Percentage of individuals who are determined eligible for Medicaid by the end of the PE period. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.1110 |
| EE13 Annual Renewals | The system uses electronic data sources to confirm eligibility, wherever possible, to facilitate ex-parte renewals. | - Percentage of individuals whose redeterminations were made using the Ex-Parte process. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.916 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE14 Annual Renewals | If ex-parte renewal cannot be completed, the system can automatically generate pre-populated renewal forms and distribute those forms via individuals' preferred communication mode. |
- Percentage of individuals up for renewal who were sent a prepopulated renewal form.
- Percentage of pre-populated renewals sent electronically and by mail. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.916 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE15 Eligibility Category | The system applies an automated eligibility hierarchy that places an individual in the most advantageous group for which they are eligible at initial application and renewal. |
- Outcome Attestation - Possibly the following:
- Test results (automated if possible) verifying that the system applies an automated eligibility hierarchy to assign individuals to the most advantageous category for which they are eligible. - Most recent PERM report and related Corrective Action Plan, if applicable. - Demonstration of system functionality to apply the eligibility hierarchy in sub-production environment. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.404 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.404 |
| EE16 Eligibility Category |
The system uses automated business rules to assign accurate eligibility categories for all the mandatory and relevant optional eligibility groups at initial application and renewal. Example business rules include:
· Correct identification of individuals age 19-64 at or below 133 percent FPL (VIII group) · Correct alignment of eligibility categories to FMAP rate | - Most recent PERM results |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.404 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.404 |
| EE17 Incarcerated individuals | Incarcerated individuals receive timely access to inpatient services and receive a timely and accurate eligibility determination upon release. |
- Number/Percentage of individuals whose eligibility status was suspended due to incarceration, if applicable.
- Number/Percentage of claims for inpatient services for incarcerated individuals. - Number/Percentage of claims paid for services other than inpatient services for incarcerated individuals. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.1009 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.1005 |
| EE18 Emergency Medicaid | Individuals whose coverage is limited to emergency services due to immigration status receive timely and accurate eligibility determination. |
- Number/Percentage of claims paid for emergency services for individuals whose coverage is limited due to immigration status.
- Number/Percentage of claims paid for services other than emergency services for individuals whose coverage is limited due to immigration status. |
For all states, District of Columbia, and territories:
- 42 CFR 440.255 For states, District of Columbia, Northern Mariana Islands, and American Samoa: - 42 CFR 435.139 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.128 |
| EE19 Retroactive Eligibility | Individuals receive timely and accurate determinations of eligibility for the three months prior to the date of application if the individual would have been eligible and received Medicaid covered services. | - Percentage of individuals who received retroactive coverage up to 3 months prior to the date of application. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.915 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE20 Effective Date of Eligibility | Individuals are promptly enrolled with the accurate effective date of eligibility in accordance with the approved State Plan. |
- Outcome Attestation
- Possibly: Test results (automated if possible) verifying that the system sets eligibility effective date according to state policy (pass/fail) - Demonstration of process for assigning correct effective dates in sub- production environment (pass/fail) |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.915 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE21 Multi-Benefit Application | In states that have an integrated eligibility system with human services programs, the system is able to pend application for one program without having to do so for Medicaid or CHIP programs, if needed. | - Individuals who apply for Medicaid on the basis of disability using a multi-benefit application receive determinations within 90 days and all other applicants using a multi-benefit application receive an eligibility determination within 45 days. |
For all states, District of Columbia, and territories:
- June 18, 2013, CMS Guidance on State Alternative Applications for Health Coverage |
| EE22 Integration with Other Programs | The state maintains a coordinated eligibility and enrollment process with all insurance affordability programs by supporting bi-directional data-sharing for application-related data and adjudication status with all relevant insurance affordability programs (FFE, CHIP, SBE if applicable, BHP if applicable). |
- Success rate of Inbound Account Transfers from the state to the FFE (The state does not need to provide data for this metric; it will be taken from the CMS Weekly AT Report).
- Success rate of Outbound Account Transfers from the FFE to the state (The state does not need to provide data for this metric; it will be taken from the CMS Weekly AT Report). - Success rate of Inbound Account Transfers from the state to the SBE, if applicable. - Success rate of Outbound Account Transfers from the SBE to the state, if applicable. - Number of applications sent to the state's separate CHIP (only applicable in states with separate CHIP programs) - Number of applications sent to the state's Basic Health Program (BHP) (only applicable in states with a BHP. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.1200 |
| EE23 Account Transfers (for FFE Determination States) | Account Transfer information for individuals applying at the FFE from a determination state is automatically ingested and the state promptly enrolls individuals determined eligible by the FFE. |
- Number of days to enroll an individual who is determined eligible by the FFE.
- Number of days to enroll an individual who is determined eligible by the SBE, if applicable. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.1200 |
| EE24 Account Transfers (for FFE Assessment States) | Account Transfer information for individuals applying at the FFE from an assessment state is automatically ingested and the state conducts only the remaining verifications necessary to complete the determination process for individuals assessed as potential eligible by the FFE. |
- Average Number of days it takes to make an eligibility determination for Account Transfers from the FFE for non-disability related assessments.
- Average Number of days it takes to make an eligibility determination for Account Transfers from the SBE, if applicable, for non-disability related assessments. - Average Number of days it takes to make an eligibility determination for Account Transfers from the FFE for disability related assessments. - Average Number of days it takes to make an eligibility determination for Account Transfers from the SBE, if applicable, for disability related assessments. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.1200 |
| EE25 Minimum Essential Coverage (MEC) Check | The system receives and responds to requests from the FFE in real-time to confirm whether an individual applying for coverage through the FFE currently has Minimum Essential Coverage through Medicaid or CHIP. |
- Outcome Attestation
- Possibly: Test results (automated if possible) verifying that the system receives and responds to requests from the FFE for MEC check in real-time (Pass/fail) |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.1200 |
| EE26 Accessibility | Persons with disabilities or with Limited English Proficiency (LEP) can submit a single streamlined application with any necessary assistance (e.g., TTY for the hearing impaired for phone applications, and language assistance for persons with LEP). |
- Number of calls using a TTY line.
- Number of requests for translation services by language. - data on the Most common Help Desk calls from applicants and Beneficiaries. |
For states, District of Columbia, Northern Mariana Islands, and American Samoa:
- 42 CFR 435.905 - 42 CFR 435.908 For Guam, Puerto Rico, and the Virgin Islands: - 42 CFR 436.901 |
| EE27 Appeals | Beneficiaries and applicants can submit an appeal against an adverse action via multiple channels (e.g., online, phone, mail, in person) and the status and adjudication of an appeal can easily be accessed by necessary state staff and appellants. |
- Percentage of appeals requested through each modality (mail, online, phone, in person).
- Number of pending appeals in the reporting period. |
For all states, District of Columbia, and territories:
- 42 CFR 431.221 |
State-Specific Outcomes - CMS Approved
States requesting enhanced FFP for systems that fulfill state-specific program needs, beyond minimum legal requirements and the baseline of the CMS-required outcomes, should propose State-Specific Outcomes which address the proposed enhancements.
When drafting state-specific outcomes statements, keep these tips in mind.
Examples for Eligibility and Enrollment
We are actively gathering and evaluating outcomes statements crafted by states for this business area.
Please send examples from your state that you’d like to share to MESCertificationRepo@cms.hhs.gov. Our team will collect and share the best examples.
| State | Medicaid Program Goal | Outcome Statement | Metric(s) |
|---|---|---|---|