MEDICAID’S ENHANCED MATCH: DEAD OR ALIVE AFTER SUPREME COURT DECISION?

There are at least three reasons why the 90/10 Federal match will not be affected by the U.S. Supreme Court’s decision this week regarding the constitutionality of the Affordable Care Act (ACA). 

First, the basis for changing the Medicaid match for IT systems is deeply rooted in federal regulation, not statute. 

In effect, CMS simply revised its own definition through regulation of the Medicaid Management Information System (MMIS), and therefore the activities eligible for the enhanced matching rates, by including eligibility determination and enrollment functionality within its scope.   This change is consistent with the way CMS, and its predecessor organization, HCFA, has expanded the scope of the MMIS over the years.  Originally viewed as a claims processing engine, the MMIS has evolved over time to include decision support systems, interfaces to immunization registries, e-prescribing and the adoption and use of electronic medical records, among many other functions.  The MMIS refers to a constellation of services designed to cover a wide number of activities, all aimed at managing the Medicaid program more efficiently.  These changes have been communicated in a variety of ways, from regulations to “Dear State Medicaid Director” letters and program memoranda. 

Prior to 1989, the matching rates for eligibility determination systems were considered part of the MMIS enhanced match.  They were reduced to 50%, by regulation, at that time for a number of reasons that have subsequently been voided over the intervening quarter century.  You can read the rationale  for why CMS chose to restore the 90/10% match for Medicaid eligibility systems.  While the ACA may have provided some impetus for CMS to revisit the definition of the MMIS, the Act itself was not the primary driver. 

Second, determining who is eligible for Medicaid services, and the services they are entitled to, has been at the hot molten core of the Medicaid universe since the program’s founding in 1965, long before the ACA. 

The decision to reduce the IT matching rate in the late 1980’s for the Medicaid component of integrated eligibility determination systems (IES) created a number of problems for the states and the federal government.  Because States were required to put up an amount five times greater for an IES than for their MMIS (50% for the former, 10% for the latter), the former tended to lag behind in technological advances.  Many states had core eligibility systems that were several decades old, with some states being hard-pressed to even find programmers skilled enough in the computer languages of twenty or thirty years ago to keep them running, much less, efficiently and effectively. 

While there were many factors in CMS’ decision to change the matching rate back to its original enhanced level, a contributor to the tipping point may have been the development of the Medicaid IT Architecture (MITA)’s Concept of Operations (ConOps).  Considered the fundamental building block of the Medicaid IT framework, the ConOps views the program from a holistic, standards-based, perspective that utilizes data from systems that are both horizontally (human services) and vertically (health) integrated.  In all cases, the Medicaid client is at the center of this paradigm, and the determination of who is eligible to be that client goes to the very heart of the program.  While MITA’s antecedents may have been lost in the mists of time, it is not too much of a stretch to say that MITA predated the ACA by at least a decade. By restoring the enhanced match for eligibility, CMS puts its (actually, the taxpayers’) money where its heart has long been.

Third, the April 2011 enhanced match regulation inextricably ties Medicaid IT improvements to CMS’ “North Star” – its Seven Conditions and Standards.

Medicaid IT systems in the future must be modular in nature, based on clear and easily understood business rules, interoperable with human services and other programs that affect the social determinants of health and wellness, standards-based, focused on results, and moving along a maturity path as described by MITA, among other characteristics.  This vision is not tied to the ACA, or any other particular piece of legislation, but deeply embedded in the program’s history and the opportunities afforded by today’s technology. 

While there may be some uncertainty regarding the future direction of health care today, CMS’ support of technology as a catalyst for program improvement has been and remains steadfast.  In short, it is not a matter of the pros and cons of the ACA; it is a matter of simple common sense.