Efforts to meet HR 1 Medicaid rules can also ‘build for the future’

The deadline for state Medicaid systems to comply with new rules for work requirements and renewals under the benefit program is on the horizon, and many states are still grappling with how to get the work done. Combining existing ex parte strategies — which automate benefits renewals using existing information — with future-looking design improvements can help states navigate new Medicaid rules. 

Under HR 1, states will be required to redetermine Medicaid beneficiary statuses every six months for Medicaid expansion populations. Certain beneficiaries will also have to adhere to new work requirements that call for them to prove they participated in employment, volunteer work or educational programs for 80 hours for at least one month prior to renewal. 

Those new rules will balloon Medicaid staff’s workloads, impacting their ability to serve residents adequately and efficiently as they battle increasingly imposing program changes, said Jen Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, during a webinar hosted by the nonprofit Code for America last week.

“States need to be looking for any place to increase efficiency, whether it's specific to the populations affected by [HR 1] changes, or overall to free up capacity to deal with these many changes and increases in workload,” Wagner said.

States should turn to their existing ex parte process as a foundation to address such challenges. Wagner noted that states could leverage 1902(e)(14) waivers during the Medicaid unwinding following the COVID-19 pandemic, for which the federal government has “pathways [for states] to continue many of the effective approaches without requiring a waiver.”

The waiver offered states additional pathways to streamline their ex parte process, such as the “zero-income strategy” that allowed renewals to occur for cases where no income was recorded or found in data sources used for ex parte, Wagner explained. Another strategy from the waiver streamlined renewals for people whose income fell under 100% of the federal poverty level. 

States must then integrate those existing systems with work requirements to leverage the ex parte process for the new Medicaid rules, Wagner said. Medicaid staff can add related data sources to their existing ex parte system, such as a person’s medical frailty information or education records, to further streamline the determination of beneficiaries' eligibility and enrollment. 

A critical piece to merging existing ex parte systems with new data sources is to change the system logic to consider work requirement compliance and exemption decisions, Wagner said. This ensures the ex parte analysis is not conducted in a single moment in time, but considers beneficiaries’ work requirement data from previous months, which can further streamline the renewal process for states. 

Changes today that support future improvements 

Despite having to overhaul many elements of state Medicaid systems under HR 1, the new federal rules offer states an opportunity to also “build for the future … not just get compliant,” said Maxwell Mazzocchi, senior principal solutions engineer at Code for America. Doing so “doesn’t have to be additional work, and you can make changes for work requirements [today] in such a way that you get compliant and you get the benefit of being future-ready.”

One way to do that is by leveraging a system’s configurability rather than upending the entire thing through a “difficult and expensive” change request process that typically involves joint application development sessions, user acceptance testing and other steps, he said.

He pointed to the ex parte renewal model, as an example. Under the model, there are several points of verification, including the determination of a beneficiary’s residency, citizenship and immigration, eligibility and community engagement. States should consider designing values like community engagement to be configurable — or able to be turned off and on like a feature — which can prepare benefit systems to change with new policies and rules more efficiently. 

“Instead of doing an entire deployment, a vendor or … state staff members, can change the configuration, and the behavior of the system changes and there is no new deployment,” Mazzocchi said.

Another future-ready strategy Medicaid leaders could implement is to set up more efficient data storage practices, because how data is stored can make data analyses easier in the long-term, he said. 

Work requirement data, for example, can be further broken down into enumerable values — or constant, standard identifiers, like if a beneficiary is a veteran or is participating in required work hours — that are valuable for evaluating a person’s exemption from HR 1 rules. The enumerable values help yield more granular data insights to, for example, inform staff’s efforts to target assistance for populations with low exemption rates. 

Ultimately, states must also consider developing new performance metrics to track and monitor their progress implementing the HR 1 changes for work requirements and renewals, Mazzocchi said. 

New metrics states can add to their reviews include work requirement exemption reasons, the data source for determining compliance and exemptions, and the number of people subject to work requirements. Mazzocchi emphasized the importance of evaluating previous metrics alongside new benchmarks, which “provides a more holistic view into your system’s performance.” 

In that case, staff can more quickly and efficiently address changes in the data sets, such as a sudden increase in the number of work requirement exemptions amid a declining ex parte renewal rate. By jointly tracking those metrics, staff can pinpoint a change in the system process that caused the two data tracks to interfere with one another incorrectly, Mazzocchi said.