Right now millions of people qualify for Medicaid and other public benefits but are not enrolled. Failure to modernize the outreach and enrollment process is a major reason why so many people are falling through the cracks of the health system. Banks have figured out how to develop systems so consumers can do nearly all their banking online. Consumers can even apply online for their vehicle registrations. Indeed, the time has come for a consumer-friendly approach to enrollment into Medicaid and other public programs. The good news is the Affordable Care Act (ACA) provides the framework for using IT to fundamentally change the enrollment process, making it easier for those who are eligible to gain coverage. This is a major victory for consumers.
As part of the ACA, the Office of the National Coordinator (ONC) was asked to develop technology standards by September 2010 for enrollment of consumers into health coverage. ONC put together a workgroup made up of a broad spectrum of stakeholders representing states, federal agencies, information systems companies, unions, and consumers. Community Catalyst Executive Director Rob Restuccia was appointed to the workgroup, and asked me to staff the process.
From the beginning, members of the Enrollment Standards Workgroup strongly advocated for consumer-friendly standards. However, members on the group who advocate on behalf consumers — including Rob, me and a number of others — clearly played an important and successful role.
Not only did the Workgroup meet its charge – regulations incorporating the workgroup’s recommendations were promulgated by Health and Human Services (HHS) Secretary Sebelius on September 17 and can be found here – but also the recommendations could transform the experience of consumers applying for and enrolling in state programs, including health insurance Exchanges.
Some of the key things the regulations call for include:
— A consumer-centered approach to enrollment. The regulation states that modernization of new and existing electronic systems are a priority in achieving a consumer-centric approach to eligibility and enrollment. — No wrong door. As ACA is implemented, consumers may become eligible for one of a variety of health coverage options: Medicaid, CHIP (for children), subsidized coverage through an insurance Exchange, unsubsidized coverage through an Exchange. The standards provide that there should be a single seamless process of applying for coverage for all of these programs – regardless of where a consumer enters the system. In fact, the standards provide, if possible, consumers should also be determined eligible for other government programs, such as food stamps, at the same time. — Reliance on electronic verification of eligibility information. Rather than requiring consumers to submit paper documents to prove their reported information, the standards provide for state systems to verify the data by checking behind the scenes with the databases of other government agencies such as the Immigration and Naturalization Service (INS) and state employment departments. The goal is to make the process of determining eligibility be as real time and paper-free as possible. — Meeting the consumer where they are. The enrollment process “accommodates the range of user capabilities, languages and access considerations,” and the process and technology standards support consumer assistance in people’s community or at their provider’s office. Community Catalyst strongly advocated for these provisions because clearly the potential of ACA to enroll 32 million NEW people in health care coverage will not be achieved unless enrollment comes to consumers and accommodates their needs and abilities.
While the regulations are a giant step forward, the Enrollment Standards Workgroup and HHS realize that this new paradigm for enrollment and eligibility is a heavy lift for states with aging Medicaid eligibility systems, budget crises, and infrastructures that may not support a quality of customer experience. The Enrollment Workgroup heard this directly from a number of states that testified before them in Washington last month and along with HHS has taken the following steps to address this:
— Workgroup standards call for a library of rules to be assembled at the federal level so states can use the work of other states in developing their systems. This rule-based approach should also enable clearer eligibility and enrollment communications to consumers. — In addition to awarding Exchange planning grants in the amount of $1 million to nearly all states, the Office of Consumer Insurance Information Oversight (OCIIO) intends to award grants to innovator states or groups of states to develop enrollment and eligibility technology that can then be shared with other states. — As part of a proposed set of rules for Medicaid eligibility systems, the Center for Medicare and Medicaid Services (CMS) has proposed to reimburse states 90 percent of the cost of developing and enhancing their Medicaid eligibility systems if they meet certain standards (including those that came out of the Enrollment Workgroup) through 2015.
The Enrollment Workgroup will to continue meet and to advise HHS and states on implementation of enrollment and eligibility standards. A new subgroup on consumer engagement will further define what a customer-centered approach means in terms of technology and process, looking at current best practices, and making recommendations by January to the larger workgroup and to OCIIO.
Community Catalyst plans to continue to participate in the Workgroup and the consumer engagement subgroup. Hub readers should let us know if you have suggestions or examples of current excellent practices that should be shared with the Workgroup. Please contact Rob Restuccia.
— Sue Kaufman, Health Care Consultant