How Do I Enroll Thee? Let States Count the Ways…

By Alice Weiss
November 2013

While open enrollment for health insurance exchanges is well underway, major changes to enrollment processes won’t begin for all states until January 1, 2014, when the Affordable Care Act’s Medicaid and Children’s Health Insurance Program (CHIP) eligibility requirements go into effect.  These new requirements, like the “no wrong door” enrollment process, standard income determination rules, and electronic verification, apply to all states, regardless of their decision to host an exchange or expand Medicaid.  To prepare, state officials have been working around the clock.

Yet, while the full impact of the ACA’s changes will be historic for states, not all of this work is entirely new.  States have been working to simplify public health coverage enrollment for nearly two decades, beginning with the delinking of Medicaid from welfare programs and continuing with innovations for enrolling children and families under CHIP.  The lessons they have learned, some of which were highlighted in a new paper released by First Focus last week, will serve states well as this next volume of coverage work begins.

Over the past four years, NASHP has supported eight states (AL, IL, LA, MA, NY, UT, VA, and WI) in their efforts to streamline enrollment systems, policies and procedures to increase enrollment of eligible children and ready systems for 2014 as part of Robert Wood Johnson Foundation’s Maximizing Enrollment program.  Maximizing Enrollment state experiences in harnessing technology, strategically managing program change, and innovating policies to streamline enrollment offer valuable lessons worth heeding in the ACA context. NASHP is documenting these lessons in a series of reports being released through January 2014 and shared in an upcoming briefing in December.  For those states working tirelessly to reach Day 1, we offer 10 lessons learned by Maximizing Enrollment states as a sonnet to inspire and support states’ momentum:

  1. Let policy drive the technology:  States found success in implementing technology solutions to streamline enrollment when technology changes originated with policy needs.  As states consider how to tailor ACA requirements and improve systems, letting policy needs drive technological changes can support successful operations.
  2. Train up for new IT environment:  A number of states found including in-house IT staff in system development to increase their technical understanding reaped great rewards.  Utah’s involvement of in-house staff in system development not only enabled the staff to troubleshoot problems but also to develop new programs to improve the system’s functionality.
  3. Don’t overlook need for workable low-tech processes:  While sleek new IT systems can offer a shiny door to enrollment, they may not be the preferred or accessible door for all, so states also need to remember human touch needs and improve consumer experience through traditional entry points, like local offices.
  4. Data, Data, Data:  As a Virginia state official put it, “data helps you prioritize. It informs policy or procedural changes and helps us figure out when a particular issue is not as big a problem as we thought it was.” States will want to make sure they can capture, report and monitor data and set up clear processes to use data for program management and performance measurement.
  5. Manage change across agencies and levels of government:  While Medicaid, CHIP, exchange and insurance agencies are most involved, the ACA program changes are impacting all agencies and levels of work.  Maximizing Enrollment state leaders found that articulating shared goals and instituting regular communication were essential to managing change inside and outside the core agency.
  6. Leadership, from top to bottom, matters:  Maximizing Enrollment states demonstrated the value of strong leadership, including a clearly articulated vision for change and empowered leaders at all levels.  Designating strong project managers to track work and promote accountability was also cited as a best practice.
  7. Engage frontline workers in the change process: Louisiana’s ground-breaking continuous (administrative) renewal strategy derived from one frontline worker’s idea for minimizing renewal burdens.  Don’t underestimate the experience, value and impact frontline workers can contribute to solving problems when they are asked.
  8. Write it on the wall: States found that re-writing policy manuals and communicating new policies through state-wide regional trainings were two ways to effectively institutionalize policy changes to standardize, protect, and communicate new policy expectations.
  9. Lighten your (case)load:  Nearly all Maximizing Enrollment states developed or implemented a strategy that allowed them to use existing data (from Medicaid, CHIP, SNAP, TANF, tax, or other sources) to make the enrollment process simpler.  States are using Express Lane Eligibility for enrollment and renewals and a growing number are using CMS’ new targeted enrollment strategies to enroll tens of thousands of eligible individuals quickly and at low cost.  Don’t underestimate the power of existing information to make the job easier.
  10. Be patient and persistent – change takes time: State experience underscored that major program change is a continuous process, more of a marathon than a sprint.  States will want to be tenacious, patient in their expectation of progress, and persistent in pushing for results as they begin their journey.

States across the nation are undertaking an historic transformation of public health coverage enrollment systems beginning in 2014. With some attention to the lessons of the past and Maximizing Enrollment states’ work, states can ensure their new efforts will be poetry in motion for the millions of Americans in need of coverage in 2014 and the years ahead.


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