Eligibility & Enrollment Systems: An Advocate’s IT Toolkit

69 Pages·2012·3.28 MB·English

by  Karina Wagnerman

Eligibility & Enrollment Systems:
An Advocate’s IT Toolkit

Overview Brief

Issue Area #1 – Will the online application and consumer web-based services be easy
to use?

Issue Area #2 – How will the system help consumers with special circumstances, such
as immigrant families and children with divorced or absent parents?

Issue Area #3 – How will the website facilitate access to personalized help from the call
center, navigators, or other assisters?

Issue Area #4 – How will the IT system use electronic data sources to verify eligibility in
real-time?

Issue Area #5 – How will the IT infrastructure coordinate coverage seamlessly between
an exchange, Medicaid, and CHIP?

Issue Area #6 – Will the web-based services help consumers compare, make an
informed selection and enroll in a health plan of their choice?

Issue Area #7 – How will the system help people maintain and renew coverage?

Issue Area #8 – How will the system protect the privacy and confidentiality of personal
information?

Issue Area #9 – Does the system provide clear information about grievance and appeal
procedures and incorporate due process protections?

Issue Area #10 – What data will the system generate to evaluate program performance
and consumer satisfaction?

Glossary

Box 57144 3300 Whitehaven Street, N.W. Suite 5000 Washington, DC 20057
T 202.687.0880 F 202.687.3110 E [email protected]
Eligibility and Enrollment Systems:
An Advocate’s IT Toolkit

by Tricia Brooks and Julie Silas
Introduction often replace decades-old technology and create
Even as states across the country continue to efficiencies by minimizing the paperwork burden New web-based IT
evaluate their options for implementing the Afford- on both consumers and eligibility workers in state, systems will serve
able Care Act (ACA), almost all states are moving county, and local government offices; reducing as the storefront to
(some quietly and behind-the-scenes) to take ad- processing delays and backlogs; improving client private insurance op-
vantage of significant federal funding to modernize communications; and producing data to as- tions in an exchange
their information technology (IT) infrastructures in sess how well our health coverage programs are and hold the promise
response to the new law.1 The decisions being performing. of revolutionizing the
Medicaid eligibility
made now and in the months ahead will have far-
The reality for many consumer or policy groups,
and enrollment experi-
reaching implications for the success of the ACA.
however, is that IT systems advocacy represents
ence.
If people feel welcomed and are encouraged to
new and potentially daunting territory, particularly
apply for health insurance through a sleek, simple-
for those with limited IT technical knowledge.
to-navigate website that easily connects them to
With this toolkit, we hope to provide some of the
coverage, it will have an enormous impact on their
background information, key questions to ask
first impressions of health reform and, ultimately,
about the system’s functions and features, and
on the ability of the law to meet its goal of bringing
strategies that advocates can use to ensure that
health coverage to almost everyone.
IT systems are well-designed for consumers and
By allowing consumers to explore health cover- promote the objectives of streamlined, simplified
age options; connect by voice or e-chat with access to health coverage. The toolkit is designed
someone who can provide more information; to be useful for advocates in states that are
secure financial assistance to pay for coverage; operating their own exchanges, as well as those
and select a health plan based on the criteria that in states where a federally-facilitated exchange
they care about; these new web-based systems (FFE) will be operating alone or in a state/federal
will be the gateway to insurance in a new market- partnership model.
place called the exchange. New consumer-friendly
Why get involved?
IT systems, linked to electronic sources of data
Even with already-full advocacy agendas and
to verify eligibility more efficiently, accurately, and
competing priorities, there are important reasons
timely than paper-driven processes, also hold the
to get involved with the development of your
promise of revolutionizing the Medicaid eligibility
state’s IT systems. These systems are vitally im-
and enrollment experience. These IT systems will
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 1
portant to the success of health reform, serving as l Speeding up the rate at which applications
the primary gateway to coverage through the ex- and renewals are processed;
change and transforming eligibility and enrollment
l Improving the quality, timeliness, and read-
in Medicaid and the Children’s Health Insurance
ability of notices;
Program (CHIP). Ensuring that consumers are
well-served by these new web-based systems is l Facilitating better access to information for
a critical role for consumer groups and advocates people with disabilities or Limited English Profi-
who have fought long and hard to improve our ciency (LEP); and
public coverage programs. The IT infrastructure is
l Promoting coordination across social ser-
vitally important to consumers because it will:
vice programs (e.g., Temporary Aid to Needy
Create the primary gateway to coverage for Families (TANF), the Supplementary Nutrition
millions. Thirty million or more people could move Assistance Program (SNAP), and Medicaid).
The IT infrastructure
out of the ranks of the uninsured with full imple-
will create the primary In many instances, the new or updated sys-
mentation of the ACA coverage options.2 Roughly
gateway to coverage tems will automate administrative tasks handled
half are expected to purchase qualified health
for millions, modernize manually by eligibility workers today. The new
plans (QHPs) through an exchange, with many
outdated administrative IT systems are expected to supplement or even
receiving advanced premium tax credits (APTCs)
procedures, carry out im- dramatically reduce the role of eligibility workers
to subsidize premiums and other cost-sharing.
portant policy decisions in gathering and reviewing paper verifications.
The other half could gain coverage through an
and shape consumer If the IT systems run as intended, consumers
extension of Medicaid to lower income parents
opinion of the ACA and will not need to supply a hard copy of recent
and other adults, along with the “welcome mat ef-
public coverage. pay stubs to establish their income. Instead, the
fect”–that is, the positive impact an expansion will
IT system will look up someone’s wages and
have in increasing enrollment among people who
sources of unearned income from federal and
are currently uninsured but eligible.3 A majority of
state databases to electronically verify income.
new enrollees are expected to sign up through on-
The resulting reduction in processing paperwork
line portals or websites, potentially with assistance
will extend the capacity of assistance offices to
from navigators or other consumer assisters.
handle the influx of new applicants and enrollees.
Ultimately, the effectiveness of these websites, and
Carry out important policy decisions. Under-
the underlying eligibility rules engine (the “brains”
neath the administrative processes, critical policy
of the system that determines eligibility using data
issues will be built into the system. For example:
obtained from electronic sources), will be instru-
how will states define when information provided
mental in determining whether the ACA meets its
by the consumer and electronic data sources,
fundamental goal of streamlined, simplified access
although different, are “reasonably compatible”4
to coverage.
and require no further review or explanation?
Modernize administrative procedures. For Which data source will trump another? How
years, consumer advocates have worked with
will the system count a pregnant woman in the
their states to streamline eligibility and enrollment
household size of her children for Medicaid? In
procedures in Medicaid and CHIP, including:
some instances, these and many other policy
l Minimizing unnecessary paper verification; questions arise during the system design phase
and may be rushed to maintain the fast pace
l Decreasing the incidence of “lost” paperwork;
at which states and their vendors need to meet
l Reducing random variation in how people are critical deadlines for IT deployment. Key policy
treated based on which eligibility worker is as- decisions may not be considered in public but
signed to their case; rather in small workgroups or advisory commit-
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 2
tees, thus it is critically important that consumer Medicaid, CHIP and the exchange.5 Thus, all
advocates call for the creation of, and participate states will need to make some changes and add
in, IT stakeholder advisory workgroups. new functionality to their current Medicaid eligibil-
ity systems. The costs of enhancing, upgrading,
Shape consumer opinion of the ACA and
or replacing Medicaid systems to meet new fed-
public coverage. For many Americans, their first
eral requirements are eligible for generous federal
experience with health reform will occur when
financial participation (FFP) at an enhanced rate
they seek coverage. Beginning in October 2013, If both the IT systems
(up to 90 percent for qualifying systems develop-
states must offer people the opportunity to sign and the underlying
ment and 75 percent for ongoing system mainte-
up for any of the insurance affordability programs policies are done well,
nance and operating costs).6
(Medicaid, CHIP, or subsidized coverage in an it will ease the paper-
exchange) through an online process. If the experi- Notably, certain cost-allocation rules for develop- work people face when
ence is a positive one at the outset, it will go a ment costs of integrated systems that process accessing or keeping
long way toward shaping first impressions of the eligibility for Medicaid and other public benefits, coverage and greatly
“real” ACA, not just the law as passed and end- such as SNAP, are also temporarily waived. (Cost improve program ad-
lessly discussed in the abstract by politicians and allocation still applies to sharing costs between ministrative efficiency.
the media. Medicaid, CHIP and an exchange, and will also
apply to ongoing system maintenance and
If both the systems and the underlying policies
operating costs for all programs.) Cost-allocation
are done well, it will ease the paperwork burden
rules require that all programs using a shared
people face when applying for or renewing cover-
system apportion the cost of development and
age. If designed poorly, however, these types of
maintenance by program. By suspending the
automated systems could create new risks for
cost-allocation requirements for a limited time,
consumers by denying them coverage based on
other programs can benefit from the enhanced
outdated or inaccurate electronic data or by pos-
Medicaid system functions and features without
ing a risk for breaches in confidentiality.
having to pay their full share of development
costs. If the Medicaid system needs a feature
What if my state will not be operating
and other programs benefit, the proportion (or
its own exchange? Will there still be
cost-allocation) that the other program will have
a significant amount of work being
to pay is limited to the cost of integrating its
done on IT systems?
specific requirements and sharing data between
States, including some reluctant to embrace the
programs. For example, if Medicaid needs to
ACA, are moving forward to update and replace
develop an online application, the cost to SNAP
their current Medicaid IT systems, impelled by
to use the online application will be limited to the
significantly enhanced federal financial assis-
incremental costs for any additional requirements
tance. No matter how a state plans to implement
(such as supplemental questions) needed only
the coverage opportunities in the ACA, the law
by SNAP. Whether they are added in the begin-
establishes new Medicaid eligibility rules based
ning or at a later date, these add-on costs must
on tax-law definitions of modified adjusted gross
be charged entirely to SNAP.7
income (MAGI) and household size, for most, but
not all, Medicaid groups. It accelerates innovations The enhanced federal funding for Medicaid
pioneered by the states to verify eligibility electroni- eligibility systems is time-limited, expiring at the
cally and streamline the renewal process. Equally end of 2015, when systems development costs
important, consumers must be able to apply for will return to a 50 percent federal match. As a
and renew coverage online and have their eligibility result, most states, at the very least, are taking
and enrollment coordinated seamlessly between advantage of this unprecedented opportunity to
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 3
upgrade, enhance, or replace their current Med- systems are updated to implement new Medicaid
icaid and CHIP eligibility and enrollment systems, eligibility and verification rules and communicate
even if they are not moving forward to establish a smoothly and effectively with the FFE.
state-based exchange.
What is the scope of the IT work that the state
States are being en-
has proposed or is undertaking? To what extent
couraged to adopt and How do I get started?
does the state plan to share components of the
adapt systems, or system There are a number of steps consumer advocates
IT system between Medicaid, CHIP, and the
components, from other can take to get up-to-speed on state exchange
exchange?
states to expedite the IT and Medicaid IT activity and prepare to engage in
development timeline the conversation. States have several options for moving toward
for both the exchange a streamlined eligibility and enrollment system.
Gather some of the basic information you will
and Medicaid. Shared systems are more cost-effective to build
need for background to understand where your
and maintain, and also ensure consistency in how
state is in process and what opportunities there
eligibility is determined across programs. States
are to engage. You can learn about what your
are also being encouraged to adopt and adapt
state is planning by getting answers to a number
systems, or system components, from other
of key questions:
states to expedite the IT development timeline
Is your state setting up a state-based exchange, for both the exchange and Medicaid.10 But not
planning to use the FFE, or entering into a state/ every state will be moving in this direction, so it is
federal partnership? important to determine what approach your state
will take.
At the one-year mark before exchanges need
to be up and running, less than one third of For states building a state-based exchange, the
the states were in the process of developing a high degree of interaction and seamlessness re-
state-based exchange.8 As of November 16, quired between exchanges, Medicaid, and CHIP
2012, states must declare which approach to an necessitates highly integrated systems. Guidance
exchange they will take.9 It is not clear whether from CMS indicates that state agencies receiving
additional states will have the time to develop or federal funds to implement a state-based ex-
adapt a state-based exchange IT infrastructure to change and upgrade their Medicaid systems are
be ready on October 1, 2013 for open enrollment. expected to share an eligibility service. However,
Nonetheless, a number of states may make deci- this does not necessarily mean that states will
sions later in 2012 to move forward with state- operate a single system, as there are different
based exchanges even if it means starting with approaches states could take to fulfill this require-
an FFE or partnership model initially due to time ment.11
constraints.
l A fully integrated IT infrastructure for both
States that are establishing state-based ex- the state-based exchange and MAGI-based
changes are responsible for developing their own Medicaid. In this situation, the state will be op-
exchange IT systems for eligibility and enrollment, erating one system that can be used simultane-
which will be fully funded by federal exchange es- ously by the exchange, Medicaid and/or CHIP.
tablishment grants through 2014. States that opt
l A shared eligibility service for the state-
to work in partnership with the FFE or strictly use
based exchange and MAGI-based Medicaid
the FFE will rely on the Centers for Medicaid and
groups. In this scenario, the exchange and
Medicare Services (CMS) for most of the develop-
Medicaid will share IT functions that produce a
ment for the exchange IT system. As noted above,
MAGI-based eligibility determination. The agen-
these states must ensure that their Medicaid
cies may share other functions or services as
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 4
well, such as the consumer portal, interfaces to Medicaid for the final determination. Regardless
the federal data services hub or state verifica- of which approach the state choses, Medicaid
tion sources, etc. They may also have different will still need to upgrade or replace its eligibility
systems or components for managing some system to handle the new MAGI-based eligibility
functions such as post-eligibility enrollment, rules, as well as new electronic verification and
case management, and renewal. streamlined renewal processes (which also apply Even in states with a
to traditional Medicaid groups). Even if the FFE is federally-facilitated ex-
l An IT infrastructure for eligibility and enroll-
making MAGI-based determinations on applica- change, Medicaid will
ment in a state-based exchange separate
tions received through the exchange’s consumer still need to upgrade or
from Medicaid. Given CMS’ expectation that
portal, the Medicaid agency may receive new replace its IT system to
states minimally share a MAGI-based eligibility
applications directly and must also be able to handle the new eligi-
service, it is not clear how federal funding works
process MAGI-based eligibility at renewal. bility, verification and
if a state-based exchange intends to have an IT
renewal requirements.
system entirely separate from Medicaid. Mini- What about traditional Medicaid groups and
mally, an electronic data interface will need to be other public programs? If the state is replacing
established so that information can be trans- its Medicaid system, what is the plan for continu-
ferred back and forth between the exchange ing to administer traditional (non-MAGI) Medic-
and Medicaid to facilitate seamless, coordinated aid groups, as well as other public assistance
coverage, while the Medicaid system will need a programs if currently managed in an integrated
make-over to comply with new eligibility, verifica- system?12 Will these programs be maintained
tion, and renewal rules. in separate systems, integrated into the new
system design upfront, or phased into the new
For states using the FFE or creating a partner-
system over time? If traditional Medicaid eligibility
ship model, the FFE will develop the exchange eli-
(i.e., disability or long-term care services) is main-
gibility and enrollment system and there will need
tained outside the new system, even temporarily,
to be an electronic interface between the FFE
a data interface will be needed to refer applicants
and the state Medicaid system to exchange client
screened as potentially eligible for other Medic-
records and other information. States have the
aid categories. Data interfaces to other public
choice to allow the FFE to make the final MAGI-
programs can and should also be built to provide
based Medicaid eligibility determination or to
consumers with efficient access to other benefits
assess Medicaid eligibility and refer applicants to
if the systems are not fully integrated.
Federal Funding for Eligibility and Enrollment IT Systems
Federal Funds State Funds Expiration
Last grant opportunity
100% through exchange
State-Based Exchange 0% submission date
establishment grants
October 15, 2014
90% federal financial par-
ticipation for qualifying IT 10% for qualifying systems
December 2015 for
Medicaid systems development (75% (25% for ongoing mainte-
development costs
for ongoing maintenance and nance and operating costs)
operating costs)
Through a temporary cost-allocation exception for develop-
ment costs only, system features required by Medicaid can
be shared by other programs. The other program will only be
Other Public Programs responsible for add-on costs (i.e., data interfaces) that are December 2015
not required by Medicaid. These add-on costs may qualify
for other federal matching funds according to each pro-
gram’s specific rules.
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 5
What steps has your state already taken to ob- oping a request for proposals (RFP).
tain funding for IT development?
l Issued a Request for Proposals to prospec-
CMS has made available a number of revenue tive vendors? RFPs are a standard way for
streams to assist states in their efforts to upgrade, states to solicit competitive bids in procuring
Since all sources of
enhance, or replace their eligibility and enrollment goods and services. Some states that had
enhanced federal fund-
IT systems. extensive system development projects under-
ing for IT systems are
way prior to the ACA or approval of enhanced
time-limited, states All sources of enhanced IT funding are time-limit-
federal funding may be augmenting current
must move quickly to ed, thus it is important that states move quickly to
contracts, rather than issuing RFPs.
take advantage of this take advantage of this unprecedented opportunity.
unprecedented opportu- Has your state: l Selected a vendor or vendors? After review-
nity to modernize their ing proposals submitted through the RFP
l Applied or received approval for enhanced
IT infrastructure. process, the next step is to select one or more
Medicaid federal matching funds for design,
vendors. States may choose to contract with a
development, implementation, or enhancement
project management firm or a systems inte-
of its Medicaid eligibility and enrollment system;
grator that is responsible for coordinating the
l Appropriated funds specifically for the state’s development and integration of different system
share of Medicaid IT system development; components from multiple vendors. If so, this
organization or team will play an important role
l Applied or received approval for IT funding as
in coordinating the IT project.
part of an establishment grant for developing a
state-based exchange; and/or l Signed a vendor contract(s)? Between the
selection and contracting process, there is the
l Applied or received approval for IT funding as
opportunity to negotiate various aspects of the
part of an establishment grant for interfacing the
contract from deliverables to price. If a state
state Medicaid/CHIP system with the FFE?
has neglected to include certain requirements
Where is your state in the design, specification,
in its RFP, there is still time to make changes if
and vendor solicitation process?
contracts have not been formally executed.
Important policy and procedural decisions (for
l Started the process of designing and build-
example, use of personal online accounts, web
ing the IT system? At this phase in the project,
portals for navigators and assisters, approach to
activity accelerates and numerous policy and
premium aggregation, etc.) are often embedded
procedural decisions must be made. It’s impor-
in vendor solicitations and/or the final contract. If
tant that any deadlines include sufficient time for
your state has not yet issued a contract, there is
user-testing, including exchange and Medicaid
still time to provide input on key issues. Has your
staff, as well as consumers. Even at this stage,
state:
contracts can be amended to include modifica-
l Completed its IT Gap Analysis? – This analy- tions or additions to the system design.
sis is an assessment of existing systems and
Which agency is in charge of the IT develop-
what changes are needed to enable a stream-
ment process?
lined eligibility and enrollment system that meets
In some situations, it will be obvious which agency
the requirements of the ACA.13 An IT Gap Analy-
is responsible for oversight of the IT develop-
sis is required to secure federal funding for IT.
ment process. In other instances, a number of
l Issued a Request for Information (RFI) from
agencies may be collaborating to design a new
potential vendors? States often issue RFIs to
or upgrade an existing IT system, leaving it less
gather information that may be helpful in devel-
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 6
clear who is in charge and ultimately accountable. ment Tool (CALT). CALT is an online tool that
Once you know which IT path your state is taking, creates a centralized repository for storing,
the next set of issues will help you identify who collaborating on, and sharing deliverables and
your target audience is or in some cases, discover products (also called artifacts) from IT projects.
there is a problem having multiple agencies work- Within the CALT, CMS has created the Medicaid
ing together with no single entity having primary State Collaborative Community to allow states
responsibility. the opportunity to leverage Medicaid information
Early and ongoing
technology (IT) systems development projects
l Which agency or agencies are involved? intervention from
and to submit products to the CALT for review
If multiple agencies are involved, have they consumer advocates
and approval. Access to this website is limited
entered into a memorandum of understanding can go a long way to
to individuals approved by each state’s access
(MOU) that clearly defines each agency’s role? ensure that important
administrator.
policy decisions are
l Does the state have a separate project man-
made with consumers
agement team (either internal or contracted)? What are the top issue areas for
in mind.
consumers?
l Has the state identified a lead agency or indi-
When upgrading or designing a new IT system
vidual person responsible for reporting to HHS?
for health coverage programs, there are many
l Who has legal authority for oversight, monitor- technical decisions that impact the consumer ex-
ing, and accountability of the IT system and IT perience. For example, states will have to decide
vendor? early in the design process whether or not to
Review the documents that are available, in- build the capacity for individual online accounts
cluding early innovator or exchange establishment that will provide an applicant with the ability to
grant proposals, federal grant awards, blueprint start, stop, and return to an application, receive
proposals, IT Gap Analyses, state RFIs, RFPs, and e-notices, update their personal information, and
vendor responses, IT vendor contracts, and other more. These features facilitate consumer self-
policy papers that include information about the IT service and enhance administrative efficiency by
system development. As you look through these maximizing the use of technology. If during the IT
documents, use the ten top issue areas (summa- system development process the contract does
rized below and detailed in separate fact sheets) to not require the inclusion of online accounts, this
begin to identify and analyze what your state may important function may not be available (even
be proposing. Some of the state IT documents in the future) and will limit consumers’ ability to
can be lengthy and highly technical. By searching manage and maintain their health coverage via
on key words, you may find relevant information the web.
more easily. Also look for sections of documents Early intervention from consumer advocates can
that describe the business requirements. Keep a go a long way to ensure that important policy
running list of questions or important features that decisions are made with consumers in mind.
are not addressed in the information available. Below we have identified and summarized top
For background information on federal funding issue areas for consumers in regard to the new
opportunities and eligibility and enrollment systems or upgraded IT systems. Separate issue briefs
requirements, see the resource list at the end of on each of the ten areas include more detailed
this brief. Additional documents have been made information and key questions advocates should
available to states through a CMS website called think about as they review documents and com-
the Collaborative Application Lifecycle Manage- municate with policymakers.
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 7
Will the online application and consumer promote self-service; whether call center staff are
web-based services be easy-to-use? Technol- able to view an application in progress; and how
ogy is easier to use than ever before. Many, if not prominently the website enables consumers to
most, consumers today are accustomed to using search for and connect with navigators and other
web-based services for banking, making purchas- assisters who can meet their needs (i.e., language
A key function of the es, or booking travel. The IT system design for spoken, evening or weekend availability).
system will be to help health care coverage under the ACA should make
How will the IT system use electronic data
consumers compare web-based access to coverage easy-to-use and
sources to verify eligibility in real-time? Tap-
and make an informed accessible for consumers. Factors such as what
ping electronic sources of data will provide states
choice of exchange the web-based services will look like to consumers
with more efficient, cost-effective, and accurate
qualified health plan. (also called the customer portal or consumer/user
ways to verify eligibility. The goal is to be able
This same functional- interface), whether a person can browse anony-
to make an immediate – or real-time – eligibility
ity could provide an mously on the website, and what languages the
decision as soon as the consumer has completed
efficient way for eli- web applications will be translated into are critical.
the application process. To achieve real-time
gible families to select Consumer testing with different types of people
eligibility and enrollment, the IT system will need to
a Medicaid managed expected to access the system will be paramount
maximize the potential for verification of eligibility
care plan. to assuring ease-of-use.
factors electronically, rather than through unnec-
How will the system help consumers with essary paperwork, by interfacing with the federal
special circumstances, such as immigrant data services hub and state sources of data.
families and children with divorced or absent The system should also include back-up options
parents? The website and online application to electronic verification, such as allowing ap-
should ensure that people with special circum- plicants to upload a scanned image or picture of
stances understand how personal information a paper document, if documentation is needed
will be used and how the programs work for their or if it provides more accurate information than
situation. For example, the manner in which the electronic sources. While real-time eligibility may
system asks questions of non-applicants, espe- not be possible if a review of documentation is
cially with regard to citizenship and social security required, enabling electronic submission can lead
numbers (SSN), matters. Additionally, helping to a faster eligibility decision.
families determine which parent should apply for a
How will the IT infrastructure coordinate
child’s coverage when divorced parents have joint
coverage seamlessly between the exchange,
custody or parents live in different states will be
Medicaid, and CHIP? To achieve the promise of
an important consumer service. These and other
health reform in the most streamlined and efficient
circumstances present special situations that must
manner, the relationship between public cover-
be taken into consideration if the system is to
age programs and the exchange needs to be
function well for everyone.
well coordinated. This is true whether the state is
How will the website facilitate access to per- establishing its own exchange or relying on the
sonalized help from the call center, naviga- FFE or partnership model. Vital to establishing
tors, or other assisters? Even when using the seamless access to all of the insurance afford-
most well designed website, consumers will have ability programs are linkages between programs
questions and some will need help maneuvering that are timely and invisible to consumers, as well
through the system to access coverage. Key fac- as appropriate screening for (non-MAGI) Medicaid
tors in determining how well the IT design provides for people with disabilities or in need of long-term
access to assistance include whether technology- care services.
enabled tools (such as e-chat) are built in to
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 8
Will the web-based services help consum- deploying new systems.
ers compare, make an informed selection
Does the system provide clear information
and enroll in a health plan of their choice?
about grievance and appeal procedures and
A key goal of the ACA is to provide consumers
incorporate due process protections? Even
with comparative data to make an informed plan
if the IT system works the way it was intended,
selection in the exchange. The ACA requires that
consumers will be denied coverage and want to
IT systems enable consumers to compare, select,
question why they are not eligible for a specific The system should col-
and enroll in a specific health plan as soon as
program. The IT systems should provide clear lect and report data
eligibility is determined. This same functionality
information on grievance and appeal rights for to evaluate program
could provide a more streamlined way for eligible
consumers, as well as access to notices and in- effectiveness, detect
families to select Medicaid managed care plans.
formation used to make eligibility and enrollment health disparities, and
Key questions about whether the system makes
decisions. The systems should include clear identify opportunities
it easy to enroll in a plan include: What kind of
pathways for consumers to initiate the grievance for improvement.
information will be available to consumers to help
or appeals process and tools to exercise their
them compare and choose a plan that meets their
due process rights.
needs in either the exchange or Medicaid? How
will that information be presented? Will the system What data will the system generate to eval-
allow consumers to enroll and then pay premiums uate program performance and consumer
online so that the effective date of coverage is not satisfaction? The IT system should collect and
delayed? report data to evaluate program effectiveness
and identify opportunities for improvement, and
How will the system help people maintain
to detect and address health disparities. How the
and renew coverage? Maintaining continuous
system tracks and reports vital measures of en-
coverage is critical to improving health outcomes
rollment and retention, how the system promotes
and measuring the quality of health care. The IT
transparency so that information is accessible to
system should be designed to make it easy for
consumers and stakeholders, and what mecha-
eligible consumers to maintain and renew their
nisms are in place to assess customer satisfac-
health coverage. It will be important to assess
tion with the eligibility and enrollment features of
how the system proposes to handle the reporting
the website are important to determining whether
of changes in circumstances and how well the
the system supports a robust evaluation and
system is able to access and use data available
ongoing improvement program.
electronically to renew coverage automatically with
minimal intervention from the consumer.
How can consumer advocates get
How will the system protect the privacy involved?
and confidentiality of personal information? Once you have the basic information and/or have
Assuring privacy and confidentiality of personal reviewed key documents about the status of
information is critically important to instill consumer your state’s IT system development efforts, there
confidence and trust in the system. Strong privacy are a number of additional steps that you can
and security protections need to be incorporated take to effectively advocate on behalf of consum-
into the system on many levels. How will the ers. Advocates can:
system communicate its privacy protections to us-
• Support your state agency requests for
ers? What steps can consumers take to correct or
funding the state’s share of IT costs. The
delete inaccurate information? What remedies are
minimal state share leverages significant
in place for breaches of security? These are key
federal funding that will result in many ad-
questions that states will need to address when
NOVEMBER 2012 CCF.GEORGETOWN.EDU AN ADVOCATE’S IT TOOLKIT 9