ACA legislation consists of several interconnected provisions, such as eligibility and entitlement determination and access to an exchange to ensure citizens are offered continuous and affordable coverage. IBM Cúram for Health Care Reform satisfies these provisions by providing a single point of entry through which citizens can shop for the full range of 'insurance affordability' programs - a collective term which includes Medicaid, CHIP, state basic health program and Insurance Assistance in the form of premium tax credits and cost-sharing reductions. Applicants can apply for assistance and if determined eligible, can enroll in the appropriate program.
To ensure a simplified and streamlined application process, information gathering is shorter than has traditionally been the case; only information that is necessary for a determination is collected. This is done by capturing details about the primary applicant, the household and the household income. Services are available through the federal data services hub (or federal hub) which pre-populates information on the application form, for example, income information retrieved from state and federal systems. An applicant has the option to use these pre-populated details rather than having to enter details themselves thus making the application process easier and quicker. Further consumer-friendly provisions are satisfied by providing assistance to individuals in a variety of ways, either through navigators who provide fair and impartial help, or through outreach assistance services.
The HCR application determines eligibility across all of the available insurance affordability programs using the same simplified eligibility rules for Medicaid, CHIP, State Basic Health Plan and premium tax credits. Consistent income rules are used for all programs where Modified Adjusted Gross Income (MAGI) is used to determine eligibility, allowing for a few exceptions for 'MAGI-based' income which is applicable only to Medicaid and CHIP. Individuals do not have the option to apply for a single program alone; determination is performed for all available health programs. This coordinated approach ensures individuals do not have to apply for multiple programs, nor do they have to apply for one program after another if they initially apply for a program for which they are not ultimately eligible. This ensures there is "no wrong door" into health coverage.
Another key provision of the ACA is to increase efficiency to help reduce agency worker workload. The federal hub can be used wherever possible to ensure client-attested information is compared to, or verified against information about the client that is maintained on other state and federal systems. This near real-time verification of client information when successful negates the need for case workers to follow up with the client for supporting documentation, allowing individuals to receive an eligibility determination and enroll in a plan in a single visit. The timely determination benefits the client, worker, and agency.