Hurdles and High Jumps on the Road to Streamlined Enrollment

By Alice M. Weiss, J.D.

February 2013

As states embark on the final stretch before new Patient Protection and Affordable Care Act (ACA) coverage options begin in 2014, most are finding their sprint has turned into more of an obstacle course, with late-breaking guidance posing new hurdles and surprises around every bend. Given all this, you would think states might be ready to slow their pace, and yet when I spoke with state officials at NASHP’s final Maximizing Enrollment grantee meeting, all reported they are committed to reaching the finish line in their work to streamline eligibility and enrollment systems and processes. There were a bunch of common themes, even though the states were coming from different political tracks and starting blocks. I wanted to share out some key ideas I heard about how state work is progressing, challenges states are facing, and lessons learned to help other states and those working with them as we begin this final lap.

No matter how far along states are, all states cited the difficulty of finishing their work within the remaining time as one of their greatest challenges. States also wished they had all the final guidance from CMS they needed to build their systems. Although this has been a common refrain since the ACA’s enactment, states are now raising this as an operational, not a political, concern. When states are being pressured by vendors to make system design decisions, they want assurances from federal agencies that they won’t be penalized for making decisions or needing to make changes later. More well-defined parameters for where a good-faith implementation effort in 2014 will be good enough is clearly something states want.

States’ eligibility and enrollment modernization “to do” lists for 2013 are long and growing, including:

  • Finalizing the Modified Adjusted Gross Income (MAGI) calculation approach, including with a central set of rules from CMS, once final guidance on MAGI methodology is available in the coming months.
  • Figuring out how to smoothly transfer eligibility determinations for mixed coverage households (e.g., where some members of the family are eligible for Medicaid and others are eligible for other insurance affordability programs or ineligible for subsidized coverage, or mixed MAGI and non-MAGI families).
  • Centralizing the eligibility determination process, or simplifying how county work can be done, as a way to streamline enrollment processes.
  • Coordinating eligibility systems and processes among insurance affordability plan (IAP) agencies, including Medicaid, CHIP and Exchange agencies, to ensure there is truly “no wrong door” as the ACA requires.
  • Moving the business process of eligibility work from case-based to task-based model. In contrast to a case-based approach where workers or offices “own” cases, a task-based model allows an agency to allocate workers’ time to the tasks needed so that cases are worked more quickly and work is parsed more effectively.

Despite the wind sprints ahead, states said they didn’t want to get off the track, fearing they would miss out on a major opportunity to change systems that have needed an overhaul for years. This feeling is clearly shared among nearly all states, as was documented in a recent Kaiser Family Foundation/Georgetown Center for Children and Families study which showed that 47 states are either implementing or seeking approval from CMS for a major eligibility system overhaul. One state official said she was afraid she might miss the chance to transform her program because she only had time to “edit what was on the page” and didn’t have time to develop a more cohesive vision.

The states we heard from had some useful advice to offer other states:

  1. Find “like” state partners – peer states and those ahead of your state – to work with and learn from as an affinity group.
  2. Don’t let the lack of guidance stop your state’s work – keep moving forward.
  3. Begin with a vision for change that all can agree upon and take the time to develop principles to guide your work – the time invested in getting all on the same page will guide your efforts as the work becomes more complex later.
  4. Contact CMS to identify other states working with the same vendor to leverage the work already being done, promote accountability and avoid recreating the wheel.
  5. Create systems to collect data on day one so your state can monitor enrollment, retention, and other state performance criteria (CMS is recommending this, too, and has issued draft performance metrics open for comment until March 8. For other enrollment and retention data metrics, check out Maximizing Enrollment and Mathematica’s issue briefs on enrollment and retention measures and tracking denials and disenrollments.

The coming year promises to be one filled with opportunities and hard work for state leaders to get ready for a massive increase in applications and enrollment. Just last week (Feb. 5), the Congressional Budget Office announced that an estimated 15 million individuals will be enrolled in Medicaid and Exchanges in 2014; millions more will apply and by 2016 the number of newly enrolled is expected to jump to 35 million. State officials looking to find like-minded peers can find them, start a conversation, review valuable charts, infographs and implementation artifacts on State Refor(u)m. Also look out for a series of reports NASHP will be sharing this summer on lessons learned from the Maximizing Enrollment Program, and check out our website for eligibility and enrollment resources.

Even as states begin this final lap of their very long sprint to transform their eligibility and enrollment systems, the advice from these leading states can quicken their pace. States, you are not alone, and help is only a click away.

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