By Beth Morrow, The Children’s Partnership
As all health advocates know, states face a daunting task
in preparing to meet the demands of ACA implementation. Building an eligibility, enrollment,
and retention system is one of the first challenges involved in getting ready
for state Exchanges’ open enrollment period on Oct. 1, 2013. Deploying such a system involves more
than just building the technology.
The design and development of this technology will be driven by complex
policy, process, and governance decisions that states are making now. With aggressive implementation
schedules, no state has the luxury of waiting before starting to design their
As California proceeds through this very consequential
puzzle, The Children’s Partnership has
written a 40-page blueprint designed to assist in that process and make sure
that consumers’ interests are front and center as decisions are made. Written by Dawn Horner and myself,
Building A Consumer-Driven Eligibility, Enrollment, and Renewal System:
Essential Design Features for Effective Health Reform in California lays out the essential design features that are required in any state for an
effective enrollment system that meets federal expectations. In California, this new system is being
called CalHEERS (for California Healthcare Eligibility, Enrollment, and
Broadly these essential design features are:
- Smart connections that allow consumers to apply for
coverage through multiple doorways (whether online, by mail or phone, or in
person) and receive consumer assistance -including live human assistance–as
- Integrated eligibility criteria and processes that
allow every consumer to apply using a single application for all programs, and
to seamlessly move between programs as family circumstances change.
- Real-time, immediate, and ongoing enrollment that
utilizes technology to obtain and verify data and eliminates unnecessary paper
- Easy navigation of coverage that allows consumers to
pick their health plan, pay premiums, and update their account through a
For each design feature, the report provides specific
recommendations (some very detailed, some more general), summarized as a tear
sheet in the Executive Summary. A
small sampling of the report’s recommendations includes:
accuracy and timeliness standards to guarantee quality of consumer assistance.
Eliminate the three-month waiting period for children
with employer coverage for Healthy Families (California’s CHIP program).
Automatically transfer children from 101% to 138% FPL from Healthy
Families to Medi-Cal (the state’s Medicaid program) and provide support to
maintain continuity of care.
Integrate human service program enrollment into
CalHEERS by the end of 2015, commencing with SNAP and TANF.
a policy that finds “incompatibility” within an application only where the
inconsistent data would have a “material” impact on eligibility – i.e., would
change the outcome.
Design the premium payment function so that consumers
receive one monthly bill for the whole family.
Our new report provides a guide for action for
California, to ensure that the state gets this right, right out of the
gate. And, while written to
address California’s specific concerns, this report can help any state move
toward a first-class consumer experience that results in individuals getting
the coverage and health care they need.