This paper was made possible in part by a grant from The California Endowment. For more information, contact Elizabeth Landsberg, Western Center on Law & Poverty: [email protected]; 916-282-5118
The Affordable Care Act (ACA) will fundamentally change the way millions of Californians will access health coverage. Instead of having to apply for a particular health coverage program, the ACA requires a seamless ?no wrong door? approach to coverage, meaning that regardless of where a person applies for health coverage she or he is evaluated for all programs and enrolled into the most beneficial program based on income and other criteria.
A number of important decisions need to be made regarding how to structure this system in California so that it is up and running by January 1, 2014. Recognizing this, the Western Center on Law & Poverty started in the fall of 2010 working with advocacy partners, in some twenty organizations, to analyze the opportunities and challenges in the ACA and make recommendations as California moves to implement the Eligibility, Enrollment and Retention portions of the ACA. While we recognize that there are additional issues related to this topic, this paper presents our analysis, recommendations, and assessment of remaining questions regarding the architecture of the new system, including electronic applications and information technology issues.
This paper addresses the structural issues involved in building the needed Eligibility, Enrollment and Retention (EER) System. This includes the application and renewal processes, verification systems, real-time enrollment, transitions between programs, and appeals.
A. No Wrong Door
California?s new Eligibility and Enrollment system should be designed to fully embrace the ?no wrong door? approach envisioned by the ACA so that no matter where and with what knowledge people apply for coverage, they get full access to all public health coverage programs and are enrolled into the most beneficial program. To achieve this goal, the new system must:
Allow applicants to apply for health coverage through any venue without having to specify the program for which they are applying. Regardless of where someone applies for coverage she should be evaluated for all health coverage programs. A person should not have to specify a program to be enrolled into it. For example, if someone thinks he is eligible for tax subsidies under the Exchange and applies for coverage online through the Exchange portal, but he is actually eligible for Medi-Cal, he must offered enrollment into Medi-Cal. Similarly, if someone applies for Medi-Cal at a county welfare office or starts a Medi-Cal application through a short-cut from a provider?s office and is not eligible for Medi-Cal but is eligible for the Exchange, that person must be offered coverage in the Exchange. This is required by the ACA.
Ensure people are enrolled in the most beneficial program for which they are eligible. Applicants for health coverage should be enrolled in the health care program with the most comprehensive coverage and lowest cost sharing. This would mean offering enrollment in Medi-Cal first, over the Exchange or Healthy Families. This too is required by law.
Use simple, consistent rules in conducting screening, eligibility & enrollment activities. Regardless of where someone applies, consistent eligibility rules must be used regarding counting income, family size and determining immigration status and residency. Without this consistency, a person might get a different result based on where she applies. A person applying online should get the same result as if they had applied in person, by phone or by mail. To achieve this, either all applications should go through the same eligibility system or they should go through systems programmed with consistent standards and managed by a single agency or entity (i.e. an inter-agency body).
California has not achieved this goal with the children?s joint Medi-Cal/Healthy Families application. Sometimes applications processed by Medi-Cal and Healthy Families reach different conclusions regarding what program a child is eligible for. This is not an acceptable outcome.
In addition to consistent rules, the eligibility rules must also be simplified as much as possible to streamline determinations and adopt an efficient process without unnecessary barriers to coverage.
All programs and entities assisting with, taking, or processing applications and renewals must have access to the same data. This point builds on using the same rules. Not only should applications be screened with the same rules and programming, but all entities involved with enrollment should have access to the full set of program rules and information. Thus a certified application assistant or county welfare worker could access the same information and system as those processing applications submitted online. To achieve this, there must be clear, consistent, and transparent standards.
Minimize information and documentation required. Individuals should be required to submit only the essential eligibility elements, as required by federal law. The EER system should, at the individual?s option, access and verify data from available databases using the minimum data elements required to determine eligibility and use that data to prepopulate an application or renewal form and complete the determination in real-time, to the greatest degree possible. When necessary, applicants can be prompted to submit additional information and documents. These issues are described in greater detail in various sections below.
Broad Coverage Options. The EER System must connect applicants to the widest variety of coverage options available, including limited scope, state-only, and/or local coverage options. Further, the verification process for Medi-Cal, Healthy Families and the Exchange should be constructed in a manner that does not preclude applicants from gaining other sources of coverage that may be available and appropriate for their circumstances. For instance, where an applicant does not meet the immigration criteria, individuals that are eligible for limited-scope services such as pregnancy-related services or family planning services under the state plan should be able to maintain coverage under Medi-Cal without cost sharing for those services while also qualifying through the enrollment process for health coverage for all other benefits.
Support the Needs of All Californians: The EER system should be designed to meet the diverse needs of all Californians seeking coverage, including:
- Providing and soliciting information at an appropriate literacy level that meets the individual?s language needs;
- Providing language assistance to those who do not speak or read English well. This includes providing culturally appropriate services in person and by phone in the consumer?s primary language and translating crucial written materials;
- Accommodating the needs of seniors and persons with disabilities, including through the use of large print and assistive technologies; and
- Accommodating the needs of families with members in different health coverage programs and different circumstances, including mixed immigration-status families.
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