State-based marketplaces (SBMs) aim to provide a “no wrong door” eligibility process for their applicants, meaning consumers can fill out one application to determine their eligibility for certain health or social services programs. Though specific approaches vary state by state, this can include subsidized coverage through the marketplace or coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
In building their marketplaces, states have several choices to foster smooth pathways to coverage — from designing systems that coordinate and communicate with their Medicaid and CHIP programs to creating systems that are fully integrated across Medicaid, CHIP, and the marketplace. States weigh the technological needs and capacities of each program with the overall cost to coordinating agencies to build and maintain systems, deciding ultimately what design will best meet the needs of their state and consumers.
In states with fully integrated eligibility systems, the SBM platform or system can determine eligibility for and enroll applicants in Medicaid and CHIP based on modified adjusted gross income (MAGI). In some integrated states, the marketplace can also determine eligibility for non-MAGI Medicaid programs and other non-health-related public assistance programs. This can include food or cash assistance through the Supplemental Nutrition Assistance Program (SNAP) or the Temporary Assistance for Needy Families (TANF) program and child care assistance programs for families.
States with separate but coordinated eligibility systems work closely with their state Medicaid agencies to assess eligibility across coverage programs. In these states, the marketplace will flag applicants who may be eligible for Medicaid programs and transfer their applications to the Medicaid agency for a final eligibility determination. Applicants flagged as potentially eligible for Medicaid will receive communication from the marketplace explaining next steps in their application process. Once their application is received, the Medicaid agency will make a final determination of their eligibility.
If they are not eligible for Medicaid, they will receive a notice and their application will be transferred back to the marketplace to determine their eligibility for financial assistance toward a marketplace plan. Consumers who initially applied through the marketplace and are found ineligible for Medicaid may be offered a special enrollment period to enroll in marketplace coverage. Similarly, applicants who applied directly through the Medicaid agency and are found ineligible for Medicaid will have their information transferred to the marketplace to determine their eligibility for marketplace coverage.
The chart below indicates the approach taken by each SBM.
State-Based Marketplace Medicaid Integration Model
Fully integrated: The marketplace’s eligibility system is integrated with the State Medicaid agency’s. Consumers who apply through the marketplace can receive a final eligibility determination for marketplace coverage, MAGI Medicaid, and CHIP.
Separate but coordinated: The marketplace and Medicaid maintain separate eligibility and enrollment systems. If a consumer applies through the marketplace but appears to be eligible for Medicaid, the marketplace will transfer the application to the Medicaid agency to make a final eligibility determination.
| State | Integration with state Medicaid agency |
|---|---|
| California | Fully integrated* |
| Colorado | Separate but coordinated |
| Connecticut | Fully integrated* |
| District of Columbia | Separate but coordinated |
| Idaho | Separate but coordinated |
| Kentucky | Fully integrated |
| Maine | Separate but coordinated |
| Maryland | Fully integrated* |
| Massachusetts | Fully integrated* |
| Minnesota | Fully integrated* |
| Nevada | Separate but coordinated |
| New Jersey | Separate but coordinated |
| New Mexico | Separate but coordinated |
| New York | Fully integrated* |
| Pennsylvania | Separate but coordinated |
| Rhode Island | Fully integrated* |
| Vermont | Fully integrated* |
| Virginia | Fully integrated* |
| Washington | Fully integrated* |
