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Cognosante MAGI Eligibility Rules

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Proprietary and Confidential MAGI Eligibility Rules MESC 2012 Boston, MA August 19-23, 2012 1
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Page 1: Cognosante MAGI Eligibility Rules

Proprietary and Confidential

MAGI Eligibility Rules

MESC 2012

Boston, MA August 19-23, 2012

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Page 2: Cognosante MAGI Eligibility Rules

Proprietary and Confidential2

The Challenge:

For states, meeting the new eligibility rules of the ACA provides significant challenges:

• Conversion to MAGI • Conflicting Regulations• New State Options and Flexibility for Medicaid Expansion

Requires investment in updating systems, operations

• State Staff Time = $$$• DDI = $$$• Short Implementation Timeframe = $$$

Page 3: Cognosante MAGI Eligibility Rules

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Federal Mandate: “Seamless Eligibility Determination”

Page 4: Cognosante MAGI Eligibility Rules

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State Flexibility: Medicaid Expansion Options

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Page 5: Cognosante MAGI Eligibility Rules

Proprietary and Confidential

– Business Logic Integration Platform – Business rules, workflow, and events

– Based on Open Source technology– Full set of Eligibility rules for determining QHP, APTC/CSR,

and Medicaid eligibility – Ability to determine MAGI Category within Medicaid

Eligibility – Capability to integrate rules with your state’s existing rules

engines– Use for HIX or IES

eSante-Rules Overview

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Page 6: Cognosante MAGI Eligibility Rules

Proprietary and Confidential

Cognosante eSante-Rules provides:– Single, stream-lined eligibility determination – Supports “No Wrong Door”– Flexible approach– Supports State Partnership Exchange (SPE) or State Based

Exchange (SBE) models

The result for States: “Speed to value”– Reduced implementation time– Reduced impact to state staff– Reduced implementation costs

6

How Cognosante can help: eSante-Rules Solution Benefits

Page 7: Cognosante MAGI Eligibility Rules

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Page 8: Cognosante MAGI Eligibility Rules

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eSante-Rules Demo: Eligibility Verification and Determination

Page 9: Cognosante MAGI Eligibility Rules

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Meet the Hood Family on January 7, 2014

Age: 39

Citizenship: LPR

Residency: TN

Income: $100

Income Type: UI

Income Frequency: Weekly

Age: 37

Citizenship: Yes

Residency: TN

Income: $2,000

Income Type: Wages

Income Frequency: Monthly

Age: 40

Citizenship: Yes

Residency: Yes

Income: $4,000

Income Type: Wages

Income Frequency: Monthly

Age: 11

Citizenship: Yes

Residency: TN

Income: $200

Income Type: Child Support

Income Frequency: Monthly

Age: 1

Citizenship: Yes

Residency: TN

Income: No

Age: 6

Citizenship: Yes

Residency: TN

Income: No

Age: 3

Citizenship: Yes

Residency: TN

Income: No

Page 11: Cognosante MAGI Eligibility Rules

Proprietary and Confidential

Hood Family Results: 92% FPL (2012 rates)

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Rule Mark Marilyn Alicia Alex Arthur Grant

Citizen LPR >5 Citizen Citizen Citizen Citizen Citizen

Residency √ √ √ √ √ √

Incarcerated No No No No No No

Tribal No No No No No No

Included in HH √ √ √ √ √ √

Monthly Counted Income $400 $2000 $0 $0 $0 $0

Household Size

Total Annual Income

6 $28,800

Parent Medicaid Child Medicaid

2 4

Page 12: Cognosante MAGI Eligibility Rules

Proprietary and Confidential

• Subject matter expertise:– Understand:

• the federal regulations and requirements,• State specific Medicaid Eligibility policies• State Goals for Medicaid Expansion

– 25+ years experience with Medicaid eligibility – Experience performing requirements analysis, rules verification for numerous state

agencies – Healthcare Reform Subject Matter Expertise

• Right Technology tools and partners– Rules engine– Ability to integrate with YOUR Exchange solution– MAGI Rules pre-loaded– Configurable for state specific programs and policy decisions– Easy User Interface, Test Rule changes before implementation

Having a rules engine isn’t enough

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Diane Zandin
insert product name/logo
Page 13: Cognosante MAGI Eligibility Rules

Proprietary and Confidential

Expertise + Tools = The Right Implementation

It’s a snap!

Contact: [email protected]

HIX Practice Lead

[email protected]

Eligibility Practice Lead


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