Getting Health Reform Right, Right from the Start: A Guide for How California (or Any State) Can Build an Effective Enrollment System

By Guest Blogger

The following blog was written by Beth Morrow, Director, Health IT Initiatives, The Children’s Partnership. This blog is cross-posted on Say Ahhh! A Children’s Health Blog.

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 system.

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 Retention System).

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 needed.
  • 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 documentation.
  • Easy navigation of coverage that allows consumers to pick their health plan, pay premiums, and update their account through a centralized system.

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:

  • Establish 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.
  • Establish 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.


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