State Based Health Insurance Exchange Individual Eligibility Business Requirements Template

The Individual Eligibility Business Requirements Template, prepared by Manatt Health Solutions, was developed in order to help drive state decisions and is based on the the eligibility business functions that state Exchanges and Medicaid agencies are required to support pursuant to the Patient Protection and Affordable Care Act (ACA), and related federal implementation regulations. The template defines, at a high level, what a state’s eligibility information technology system must do to fulfill Exchange and Medicaid business needs for QHP and insurance affordability program eligibility determinations, including Medicaid, CHIP, the Basic Health Program (should the state implement one), and premium tax credits. Noted throughout the template are state policy decisions that will drive eligibility determination process and business requirements. These decisions include the state’s reasonable compatibility standard and whether navigators, agents, brokers and other third party assisters will have a designated portal access to the Exchange. While the template reflects federal requirements and state options, states may build on this model to include state specific eligibility requirements. This template may be useful to states in developing both Exchange requirements and modernized Medicaid eligibility system requirements.

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