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HHS's essential health benefits bulletin is less than two months old--in fact, the comment period just closed this week, click here for our comment letter--but some states are already planning for what it could mean for their residents.

The Bulletin indicates that states will be able to choose the core of their essential health benefits package by copying the benefits from one of ten existing health plans.  That immediately raises the question--what do those ten plans cover? And which one would be best for kids, families, and all health insurance consumers?

Answering these questions will be complex, but a great way to start is to look at the ten plan choices side-by-side to compare what they cover.  In Maine, the Department of Insurance has put together a helpful table that compares coverage across plans in some key benefit categories.  It's by no means a complete analysis, but it's a great way to begin this important comparison.

Have you seen a similar document in your state?  If not, it could be something to ask your state's insurance regulator to put together.  Of course, you'll still want to make sure that the full plan documents that provide detailed coverage information are released publicly for each of the potential benchmarks before your state's selection is made.  But getting the plan comparison underway with a summary table like Maine's can be a good way to get started--the Bulletin says states should choose their benchmark plans by the third quarter of this year.      

Editor's Note: This is the fourth blog in a series on essential health benefits.

By Leigh Cobb, Advocates for Children and Youth

and Suzanne Schlattman, Maryland Citizen's Health Initiative Education Fund

Maryland has just received its second Children's Health Insurance Program Reauthorization Act (CHIPRA) performance bonus from CMS.  This recognizes its efforts to identify and enroll eligible children in Medicaid and the Children's Health Insurance Program (CHIP).  Maryland enrolled an additional 41,000 children in FY 2011 alone, and since 2007 we have seen a 34% overall increase in enrollment.  Our bonus of $28.3 million represents the highest amount awarded by CMS this year.

Streamlined eligibility and enrollment have long been a priority for Maryland advocates. However, at the time CHIPRA passed, Maryland met 3 only of 5 required bonus criteria: it had eliminated the asset test, adopted a single, simplified application form for Medicaid and CHIP, and eliminated the in-person interview requirement.  The state had begun to recognize that many children continued to fall through the cracks and lose coverage as a result of our renewal process.  To address this, Maryland streamlined and automated the renewal process in 2009.  Still, Maryland had to take one more step to become eligible for a CHIPRA performance bonus.

In 2008, Maryland had passed the Kids First Act creating a national model.  Under the legislation, the state tax forms included a question to determine if dependent children had health care coverage.  A combined Medicaid/CHIP application was then sent to all families with incomes under 300% of the federal poverty level who indicated lack of coverage for their children. The State then recognized the need to create even more targeted outreach.  In 2010, with substantial support from the advocacy community, the legislation was modified to facilitate better coordination between the Comptroller's Office and the Department of Health and Mental Hygiene (DHMH).  At the same time, it added a separate opt-in provision to the tax form.  These steps led to the realization of true "express lane eligibility" and allowed the State to apply for and receive its first CHIPRA bonus.  The State also piloted another express lane eligibility effort that uses Free and Reduced Meals (FARMS) program applications in Baltimore City.

The substantive expansion in enrollment in 2011, made Maryland eligible for this year's Tier 2 bonus--because it increased enrollment more than 10 percent above the target level needed to earn a bonus.  Commenting on the latest performance bonus and the lessons learned from child enrollment efforts, DHMH Secretary Dr. Joshua Sharfstein said, "We have a great foundation for further progress with the Health Benefit Exchange".

This second performance bonus will support Maryland's ongoing efforts to make sure that all eligible children get enrolled in Medicaid and CHIP, and can then access the full range of health services they need.

Medicaid stakeholders have a new resource to mine in "Medicaid.Gov." CMS opened the mine on Monday for prospecting and you're bound to find, through the site's updated search functionality, some of those elusive nuggets of information previously not available or buried so deep within the old CMS website that no amount of blasting could unearth. An example of the ease of use is that State Medicaid Letters, State Health Official Letters, Informational Bulletins and Regulations now are available in a single location and searchable by topic. So no more panning in separate places to access the different sources of information on the same topic.

The CMS announcement of the new site noted that it is part of the agency and administration's promise to transparency and information sharing (thanks to our friends at CMS). Evidence of the commitment to transparency is the reporting of approved and pending state waivers, a true "Mother Lode" for state advocates.

Other Medicaid and CHIP nuggets you'll discover as you pan through this new website, which are searchable by population, topic or state, include:

* Eligibility, benefits and cost-sharing

* Outreach and enrollment policies such as Presumptive Eligibility or Express Lane Eligibility

* Enrollment data (total served, not point in time enrollment through 2010)

* State templates

* Audio Recordings of the recent National Enrollment and Eligibility Conference

* Links to the Code of Federal Regulations embedded at strategic places

* Frequently asked questions

Like any website, it's a work in process. I came in short on a couple of searches. For example, I couldn't find State Medicaid or CHIP Plans. It would be great to see them there, including approved and pending state plan amendments (SPA). Of course, it also would be great to see current state-by-state enrollment, disenrollment and other data posted regularly. And the challenge for CMS (and any website host) is to keep the site current in this fast-paced policy environment.

If you've bookmarked any pages on the old website, you'll be directly to similar but not always the same information on Medicaid.gov. For example, my old link to State CHIP plans brought to me to a section about CHIP program design but not the State CHIP plans.

There's a prominent icon/link to submit website suggestions. So be sure to give feedback when you find a shiny nugget or when your panning comes up with rocks and not precious metal. You can also sign up for regular updates by going here.

We've written before about Arizona's response to the recession--substantial budget cuts and the only enrollment freeze in the nation in its CHIP program, KidsCare. Instituted almost two years ago, there are now 129,000 kids on the waiting list for access to affordable health coverage.

A new (but somewhat familiar) proposal has emerged to provide coverage to a small share (about 19,000) of these children. While efforts to ease the burden on these families are encouraging, they certainly don't go far enough to address the larger problem.

Three hospitals have banded together to pony up $60 million a year for the next two years to help pay for care for those without coverage. In return, Medicaid funding will increase $114 million to help finance that care. There's a stipulation, however, from CMS that requires some of those funds go towards the KidsCare program. So, the hospitals are going to throw in another $10.7 million (which will also be matched by CMS) to provide coverage to some children on the waiting list.

While this will make a dent in the waiting list and certainly help thousands of families, it raises questions about the strategy: If health care providers step in with a match does it remove the state from its responsibility and commitment to cover kids and help families who need it most?

The question is not new, but it comes up again as officials look to help at least some struggling families now.  The risk - and ultimate question in the long run - is setting up a system that allows the state to shirk its responsibility and pass the buck onto hospitals. Meanwhile, all other states, including those also in dire fiscal shape, have found ways to maintain their commitment to children and families.  Arizona, however, enacted new corporate tax cuts that will cost the state nearly double  the amount necessary to fully lift the freeze in 2012. And now they're turning to the hospitals to address the shortcoming.

This week, CMS released a Q & A on State-Exchange Implementation with new information on several topics, which are described below. Of concern and worth highlighting is the disappointing departure from the proposed rules by now allowing states that choose not to implement a state-based exchange to retain control over Medicaid and CHIP eligibility. The Notice of Proposed Rulemaking (NPRM) issued on August 12, 2011 supported the vision of a seamless, streamlined system, ensuring that the Exchange would determine eligibility and enroll all applicants in the program that best matches their circumstances, be it Medicaid, CHIP, the Basic Health Plan or subsidized coverage in the Exchange. Instead, the Q & A allows the state to opt for the federal exchange to only conduct a preliminary assessment of Medicaid and CHIP eligibility, leaving the final determination to the Medicaid or CHIP agency.

This concept is similar to the "screen and enroll" provisions currently in place for Medicaid and CHIP that have yet to be perfected. It has taken years to identify and fill the cracks in the system and this experience has shown that a single point of entry and single eligibility system results in fewer eligible individuals slipping through the cracks. The new option offered to states in the Q & A perpetuates the current bifurcated system. This will require more concerted oversight and tracking to ensure that the "eligibility handoff" is successful. If CMS is not going to fulfill the full promise of a seamless, streamlined system, then it will be critically important to establish strong performance metrics (and penalties) to ensure that individuals and families are not asked to provide the same information to multiple agencies and that specific timeliness standards are met.

Another new option potentially will allow states that choose to establish a state-based Exchange to access federally-managed eligibility determinations for premium tax credits and reduced cost-sharing reduction, access to minimum essential coverage and exemptions to the individual mandate. It is somewhat unclear if CMS intends to simply do the determinations for states or allow them access to a new "shared service." This option has major implications for state information technology (IT) systems, in particular, giving states more time to upgrade or build new eligibility systems of their own.

In addition to the new eligibility determination options, the Q & A also provides the following information:

Costs to States - For those states that choose to have the federal Exchange determine eligibility for Medicaid and CHIP, there will be no cost to states for the eligibility determination. However, states will be required to share in the cost of the interfaces needed to exchange data. States also will not have to pay for data accessed through the federal data services hub, which will provide eligibility information including modified adjusted gross income (MAGI), as well as citizenship and immigration status.

Exchange Establishment Grants - The clock has been ticking on securing Exchange establishment grants with the final of three more rounds of funding set for June 29, 2012. The Q & A indicates that CMS will modify and extend the deadline for applying for these grants.  It also discusses how Exchange planning or establishment grants can be used in exploring and implementing the Basic Health Plan Option.

IRS Data - The Q & A outlines the data that will be available through the federal data hub, which does not appear to be all the data needed to verify applicant information such as the names of all tax dependents.

Quality Ratings for QHPs - States will be given more time to develop QHP-specific quality measures. CMS is proposing a phased approach to the quality rating provisions in which quality ratings in 2014 would be based on existing quality metrics and measures, transitioning to a QHP-specific rating in 2016.

Audits - The Q & A reassures states that audits will be based on current federally-approved state policy. So for example, if a state allows (and the federal government approved the state plan for) self-attestation of income, then the statement of the applicant, not other data, will be used for audit purposes.

Other - There's more in the Q & A on risk adjustment, coordination of the federal exchange with existing state insurance rules and multi-state plans.

It's helpful to see more details emerging on the implementation of exchanges, but many questions remain unanswered. Keep checking Say Ahhh! for the latest news from Washington as we continue on to 2014.

By Lisa Han, The Childrens Partnership

Recent data shows that people of color and low-income populations are adopting mobile technology at a rapid pace and are increasingly using mobile tools to access the Internet. These tools enable new ways of interacting with the government and enrolling in public services.  Instead of standing in line at the DMV, renewing a driver's license can be done more conveniently from a mobile device, and important notifications, such as status updates from the Department of Homeland Security, can be received through text messages. With mobile phones - particularly smartphones - there is an opportunity to make applying for and retaining health insurance as easy as checking Facebook or buying movie tickets.   And, because these tools can reach families that are disproportionately uninsured, mobile enrollment could help reduce disparities in access to care and health coverage.

Why are mobile phones a good way to help enroll people into MediCal and Healthy Families?

An 87% cell phone ownership rate among people of color demonstrates that mobile phone technology is a routine part of their lives.#  A recent Pew report indicates an increase in smartphone ownership among all racial and income groups, as well.# In fact, one in three cell phone owners has a smartphone, and Latinos and African Americans have overall higher than average adoption levels of smartphone ownership at 44%.#

Meanwhile, Latinos and African Americans are twice as likely (38%) to use their cell phones to access the Internet than Whites (17%).  In addition, in households with incomes under $30,000, 40% of those who own a smartphone report using it as their primary source of access to the Internet.

Given these new realities, states should begin to explore how to use this technology as a way to increase coverage for people of color and low-income families, since enrollment and renewal of subsidized health coverage is increasingly occurring online.  In California, over 75% of the uninsured are people of color, and 3 out of 5 are Latino.# Among them, over half a million have income levels that qualify for the MediCal or Healthy Families Programs, but they are still not enrolled.#  As noted above, these families use cell phones, including smartphones, to send texts, access the Internet and perform other daily tasks.

How can mobile enrollment help families?

Innovative methods of outreach and enrollment through cell phones and smartphones can specifically help unreached populations in several ways - both in the immediate moment, and in the future as these technologies are further developed.  Peter Lee, the Executive Director of the California Health Exchange, recently identified the need to explore smartphone applications, texting, and even social media as new technologies to give consumers more access to health care and enrollment avenues.

The popularity and ease of using text reminders with regular feature cell phones have already been demonstrated.  For example the text4baby program, which provides individualized health information to pregnant women by text message, enrolled 131,000 pregnant users in its first year. In addition, smartphones are being used to start an application for Medicaid and generate follow-up assistance to complete the process. One example is Hudson Health Plan, a New York Medicaid managed care plan, which has a mobile optimized site that even allows users to pay premiums and find doctors from a mobile device.

Furthermore, as smartphones proliferate, along with the access they provide to sophisticated applications and the Internet, more people will use these types of mobile devices for complex tasks like enrolling, renewing, and managing health insurance.  In fact, after health reform is fully implemented in 2014, online enrollment processes will most likely be the norm. With proper incentives and guidance, smartphone 'apps' could be developed to enable convenient application, renewal, payment, and communication with MediCal, Healthy Families, and the California Health Benefit Exchange.

How can we make sure to leverage this tool for decreasing disparities?

It is important that California do its utmost to leverage the value of mobile technologies in its development of online enrollment systems, given the high rate of adoption of smartphones and related Internet use among people of color and low-income households that traditionally experience high rates of uninsurance.  To move forward in this effort, California will need to ensure that its online application is designed in a manner that: is mobile accessible across multiple platforms; has adequate security regardless of cell phone provider; and does not cost families more than their current cell plan costs.  Early input from parents and other consumers in underserved populations, as well as usability testing, must guide the process to make sure it works for families.

For more information, see Mobile Technology:  Smart Tools to Increase Participation in Health Coverage at www.childrenspartnership.org/

By Jenny Sullivan, Enroll America

My colleague Ani and I had the pleasure of attending the Second National Children's Health Insurance Summit earlier this month in Chicago. The gathering, hosted by the Centers for Medicare and Medicaid Services (CMS), was the official kick-off for the second round of outreach and enrollment grants that CMS awarded to 39 different groups in 25 states to get kids enrolled in Medicaid and the Children's Health Insurance Program (CHIP). CMS awarded $40 million across five focus areas: technology, retention, engaging schools, targeting groups likely to experience gaps in coverage, and concentrating on teens. Over the course of the three-day meeting, we got the opportunity to hear from a wide range of groups that are involved in children's outreach and enrollment, including community health centers, managed care plans, providers, communications and technology firms, state agencies, and consumer groups. Conference attendees, many of whom have a wealth of enrollment-related experience, shared lessons learned from the last round of grants (2009-2011) as well as their plans for the next few years. And wow, are these groups busy!

Grantees and non-grantees alike are actively engaged in reaching out to the remaining uninsured children, many of whom are likely eligible for Medicaid or CHIP. This is important to our mission at Enroll America for two reasons:

• Efforts to reach out to low-income families and enroll children in Medicaid and CHIP are directly instructive to the outreach efforts that will be needed in 2013 and beyond. Many of the parents of Medicaid/CHIP-eligible children will be newly eligible for coverage through Medicaid or health insurance exchanges in 2014. Identifying the best ways to reach these families to enroll their children gives us clues about how to enroll their parents when they are eligible for coverage in 2014.
• The more eligible children who get--and keep--coverage now, the fewer people there will be who need to enroll by 2014. 

We'll blog about some of the innovative projects these grantees are working on in the coming months. For example, the Michigan Primary Care Association is using a technology-driven model to improve renewal rates by texting families to remind them to renew and by providing renewal assistance over the phone and online. The South Carolina State Office of Rural Health is partnering with The Benefit Bank of South Carolina to connect the existing Benefit Bank technology to the South Carolina Department of Health and Human Services' eligibility determination system. They are also going to use tablets with cameras to capture applications and supporting paperwork and to submit applications electronically. This helps reduce the paperwork that families need to submit and expedites the application process.

We're looking forward to highlighting other grantees' work in future posts. If your organization is a grantee and has a great idea to share with our readers, let us know! 

Secretary Kathleen Sebelius, U.S. Department of Health and Human Services  

No child or young person should have to skip a doctor's appointment or go without the medicine they need because their family can't afford it.  That shouldn't happen in America, and that's why the Obama Administration made children's health coverage a priority from the start.

When President Obama took office, there were 8 million uninsured kids in America, roughly two-thirds of whom were eligible for Medicaid or the Children's Health Insurance Program (CHIP), but were not enrolled.  That was unacceptable.  So one of the first bills the President signed was the Children's Health Insurance Program Reauthorization Act (CHIPRA).  That law not only expanded coverage to four million additional children, it also included a range of bonuses and grants to help states and community partners strengthen their enrollment efforts.

To raise these efforts to the next level, on the first anniversary of CHIPRA, I issued the Connecting Kids to Coverage Challenge:  I called on Governors, Mayors, pediatricians, faith groups, school nurses, sports coaches, community organizations, and others to work with us to cover all five million children who were eligible for either CHIP or Medicaid but weren't signed up.

All over America, that call was answered, and today, with the help from States and communities, we have reduced the number of eligible but unenrolled children nationally and in every region of the country.  For example, Oregon has enrolled more than 100,000 eligible children in Medicaid and CHIP over the last two years, cutting its percentage of uninsured children in half. 

These are achievements we can be proud of, but we also know we can do more to give families the security of knowing their children are covered.  That confidence is critically important to parents. In a national survey we conducted to find out what parents of eligible children think about Medicaid and CHIP, 70 percent said that when it comes to enrolling their child, getting "peace of mind" is a very motivating factor, as well as the knowledge that the programs are affordable.  Perhaps even more important, parents told us that they value what the programs provide their children: two thirds of the parents whose children were covered said they were very satisfied with the coverage and the quality of health care their children get with Medicaid and CHIP. 

While these high marks are affirming and bolster our efforts to promote Medicaid and CHIP, the survey also revealed that far too many parents still don't know their children may be eligible, may think the enrollment process is too difficult or don't know where they can apply.

This summer our Department released another $40 million in CHIPRA outreach grants to build on the grants awarded in 2009.  We directed this round of funding at strategies we know are working and have the potential to do the most good.  They'll support efforts to use technology in new ways to sign up eligible kids, help generate outreach activities in schools and focus attention on teens and minorities, groups for which coverage gaps still exist.  And thanks to the Affordable Care Act, there will be more outreach funds available soon to support this vital work.

For more information, check out our website, www.insurekidsnow.gov , for valuable resources.

- Flyers that promote Medicaid and CHIP in English and Spanish;

- Ideas for enlisting schools, community health centers and local businesses in outreach;

- The Game Plan, a guide for engaging school and community youth sports programs in helping to enroll eligible children in health coverage, and

- Our growing Outreach Video Library that spotlights effective techniques and promising practices being used across the country to enroll eligible children and teens

Ultimately, it's people on the front lines who help make sure eligible children and their families have the security that comes with health insurance. Working together, we can move even closer to the day no child in America goes without the care they need because they don't have health insurance.

Editor's Note: Organizations can answer Secretary Sebelius' Call to Action by accepting the Connecting Kids to Coverage Challenge.  It's easy:  Just visit www.challenge.gov/hhs/54 and follow the instructions. Those who have already accepted the challenge are encouraged to share what they are doing on the same website.