Eligibility and Enrollment in the Exchange

Covered California Must Make it Easy to Enroll

In its role as active purchaser the Covered California must become a proactive force of change in the California health insurance market. Covered California needs to reduce the confusion involved in qualifying and enrolling in health insurance for all Californians. It must assist consumers with understanding and choosing appropriate plans, but also leading qualified individuals to existing government programs like MediCal. The Exchange must meet or exceed the enrollment goals envisioned in the Affordable Care Act. The Exchange platform must be able to ask a handful of initial qualifying questions and make a preliminary determination if an applicant may be eligible for MediCal, Healthy Families, or a subsidy through Covered Californi.

The Exchange Platform Must Enroll Huge Numbers

The Affordable Care Act (ACA) established an individual mandate to obtain health insurance. An estimated 3.5 million Californians will be eligible for federal premium subsidies to cut the cost of their health coverage when they begin buying policies through the Covered California in 2014. An additional 1.9 million will qualify for expanded Medi-Cal coverage.

Small Businesses Enrollment

The Small Group Option Program or SHOP Exchange is a separate exchange specifically for the small business health insurance market. The SHOP exchange will track coverage selection and eligibility at the individual level even though the individual is a member of a group. For example, John Doe might be attached to an employer for a period of time, then become an unemployed individual who would be billed directly, then might be hired by another employer. None of these events should have an effect on the portability of coverage through the Exchange. The SHOP Exchange will provide a centralized online portal that can perform both enrollment and underwriting, showing only qualified options to a given enrollee. All enrollment and eligibility information is maintained by the Exchange and forwarded electronically to the carriers. The Exchange also manages all adds, changes and terminations. The role of the employer will change from one of health plan selector and administrator to that of partial financer.

Enroll Medi-Cal Recipients

In 2014, enrollment in Medi-Cal, as the Medicaid program is known in California, is expected to increase by 1.9 million, or more than 20 percent. California has received a $10 billion federal waiver that will enable the state, in the years leading up to 2014, to identify and enroll uninsured low-income Californians in health care coverage offered by California counties. In 2014, the state will be able to enroll these Californians into Medi-Cal or into subsidized plans offered by Covered California or Medi-Cal, depending on their income, without disruption in coverage. Today, there are hundreds of thousands of people eligible for the Medi-Cal program but not enrolled in it. The ACA also provides grants for the Exchange to add significant outreach to these people..

Interface 
with
 Other Public
 Programs


The 
ACA 
and 
subsequent 
HHS 
guidance 
envision 
exchanges 
enabling 
"real
time" determination 
of
 eligibility 
for 
not 
just
 coverage 
through 
the 
Exchange 
but 
for 
all
 health programs.
 This 
will 
require 
specific 
information 
from 
customers
 which 
then 
must 
be 
verified 
using 
federal 
and 
state 
sources. 
AB1602
 not 
only
 codifies
 the 
federal
 requirement 
that
 the 
Exchange 
inform 
individuals
 about 
their 
eligibility 
for 
other
 public
 programs, 
but 
it
 also 
calls
 for 
the
 Exchange 
to 
coordinate 
enrollment 
with 
these
 programs. 
These 
programs 
should 
not
 only 
include 
Healthy
 Families
 and
 Medi‐Cal, 
but
 should 
extend 
to 
CalWORKs,
 CalFresh,
 WIC 
and
 others.



Enrollment IT Standards

In January 2014, with the full implementation of the Affordable Care Act (ACA), consumers will open one door at the California Health Benefit Exchange and it will lead them to Medi-Cal, Healthy Families, health insurance premium tax credits, exemptions from the mandate, and private coverage. By January 2014, policies, procedures and enrollment IT systems will need to support this new vision. To this end, while new eligibility rules and other operational policies are still being ironed out, the Secretary of Health and Human Services recently adopted a series of Enrollment IT Standards for use by states and federal agencies implementing ACA. The standards were mandated by Section 1561 of the health reform legislation, developed by a workgroup of stakeholders co-chaired by U.S. Chief Technology Officer Aneesh Chopra and California Healthcare Foundation Vice President Sam Karp, and are now posted on the web site of the National Coordinator for Health Information Technology. At a high level, the standards support the following vision:

  • All people have the opportunity to make informed choices about their health coverage and other benefits.
  • Consumers apply online, renew coverage online, and learn about final determination online.
  • Systems talk to each other and share and store information so consumers don't have to provide the same information over and over again.
  • Information provided for one program is used to support consumers through their permission and direction in applying for other programs for which they may be eligible.
  • Consumers will be able to see data provided by federal verification systems and provide appropriate updates or information to validate their current situation.
  • Consumers will be able to download and re-use the information they provide for program eligibility for other purposes, similar to the Veteran's Administration "Blue Button" approach.
  • The process is transparent and enables consumer participation, thereby reducing burden on everyone -- including states and counties.

While it may seem overwhelming to imagine getting the California enrollment system from where they are now to where they need to be in 2014, the good news is current technology has the ability to handle connectivity and communication among different systems regardless of how they are built and how they function. Because California does not have the resources or time to rip and replace legacy systems to accommodate the changes required by ACA, learning about and implementing newer solutions for integration will be critical. That said, the clock is ticking and is important to begin assessing their systems against the standards that have been posted and learning about integration solutions now.

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