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