Health Reform
Implementation:
Opportunities For
Place-Based Initiatives
Community Roles in Maximizing
Eligibility and Enrollment In California
Gerry Fairbrother, PhD, Senior Scholar
Tara Trudnak, PhD, Senior Research Associate
July 2012
This issue brief, the fourth in a series on health care reform and place-based initiatives, was
prepared with funding from The California Endowment and the Community Clinics Initiative
1
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How does eligibility change under the ACA? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The current pre-ACA eligibility framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Eligibility framework under the ACA: The basic structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Eligibility framework under the ACA: Tax-based eligibility rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Subsidies, payments and penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ensuring continuous coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What is the expected impact of the ACA on population coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Potential impact of the ACA coverage expansion for Californians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Potential impact of the ACA on coverage for children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
National impact if “Maintenance of Effort” for Medicaid and CHIP is rolled back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What systems are being put in place at the state and county levels to determine eligibility and to facilitate enrollment? . . . . . . . 10
California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Interfaces and integration between CalHEERS and other data systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
What are some issues/special concerns for the next stages of implementation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Attention on coverage renewal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Optimal use of large data systems at the state and federal levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Ensuring coverage in families with complex eligibility situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Undocumented immigrants not eligible under the ACA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
How can eligibility and enrollment be maximized and made most efficient at the local/community level? . . . . . . . . . . . . . . . . . . . 14
Set up systems for in-person application and enrollment assistance at the community level in order to make enrollment
processes as accessible as possible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Focus on families and children with complex eligibility situations and families at difficult transition points,
to ensure that high-need families do not lose coverage because of their situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Set up systems to monitor coverage continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Ensure that the platform for enrollment into health insurance coverage also serves as a platform for enrollment
into other needed social services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
The Road Ahead: Realizing the Promise of Health Care Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
About this Brief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Introduction
The Patient Protection and Affordable
Care Act (ACA) opens an unprecedented
window of opportunity for providing
greater access to health care, improving
health status and offering new health
care coverage options. No longer will
job loss, divorce, or simply turning 18 be
accompanied by loss of coverage. Instead,
expanded coverage under the provisions
of the ACA should reach the uninsured
population of 47 million individuals
nationally and 2.3 million in California.1
After the ACA is fully implemented, all
citizens and legal residents will be eligible
for some form of coverage. Done well,
implementation of the ACA will create
a “Culture of Coverage” in which health
care is viewed as a right and available
to – and required for – all citizens and
legal residents. The challenges for states,
counties and for local leaders who are
committed to improving health outcomes
will be in determining which type of
coverage and what subsidies an individual
or family might be eligible to receive – and
then ensuring that coverage is secured and
continuous.
California is moving proactively to
implement the ACA. State officials
began expanding coverage for currently
uninsured individuals by using a Medicaid
Section 1115 waiver to launch a five year
“Bridge to Reform” program. The state is
setting up a Health Insurance Exchange
and other mechanisms authorized under
the ACA to support the new coverage,
subsidies, and related provisions.
Directly relevant to the subject of this
paper, the state has begun designing
new eligibility and enrollment processes,
since eligibility determination under the
ACA is substantially different from the
current system. Rather than relying on
the complicated income-based eligibility
rules now used, income eligibility under
the ACA is based on a standardized
method for determining an individual’s
or family’s income, the Modified Adjusted
Gross Income standard (MAGI), as
defined under the federal tax code. This
new approach to eligibility will allow
California and other states to create a more
unified and hopefully more streamlined
application and enrollment processes
for health care coverage under the ACA.
In sum, the ACA offers unprecedented
opportunities to maximize enrollment
of individuals, families and children into
a health insurance program and ensure
continuity of coverage.
For local leaders to take full advantage
of the new coverage opportunities,
however, they must first understand the
new eligibility and enrollment provisions
as they apply to real-life situations. This
Issue Brief provides local leaders with
basic information they need to be effective
advocates on behalf of residents of their
county, city or neighborhoods. The brief
(a) describes how eligibility for health
care coverage changes under the new
law, (b) summarizes the expected impact
on currently uninsured populations, (c)
provides key facts about the systems of
eligibility and enrollment being put in
place at the state and county levels, (d)
highlights issues of special concerns as
implementation moves forward, and (e)
recommends issues that local leaders
should attend to in order to maximize
the efficiency and effectiveness of new
eligibility and enrollment processes. These
recommendations are summarized in Box
1 and described in more detail in the final
section.
The focus of this issue brief is on the
state of California, but the brief is
intended to inform a broader audience of
community-level advocates and leaders
who promote the health and well-being
of residents within a defined geographic
area (e.g., neighborhood, city, or county).
Equipped with information, leaders who
are in a position to assist with eligibility
determination and enrollment within their
communities can translate new policies
to the people they serve and can further
represent community needs to state
advocates and policymakers.
How does eligibility
change under the ACA?
Eligibility determination criteria and
processes change radically under the ACA
from their current framework. Current
rules target health care coverage to lowincome individuals, with restrictive
eligibility thresholds and cumbersome
Box 1: To maximize coverage under the ACA and make enrollment and
eligibility efficient and effective, local leaders can:
n
Set
up systems for in-person application and enrollment
assistance at the community level in order to make enrollment
processes as accessible as possible
n
Focus on families and children with complex eligibility
situations and families at difficult transition points, to ensure
that high-need families do not lose coverage because of
their situations
n
Set up systems to monitor coverage continuity
n
Ensure that the platform for enrollment into health insurance
coverage also serves as a platform for enrollment into other
needed social services
3
rules that use income, assets, and disability
status for determining the income
thresholds. Even for children, for whom
the income eligibility thresholds are
more generous and who generally are
exempt from the asset test, the rules for
determining income are complex and
cumbersome. Under the ACA, there will
be two major changes. First, all citizens
and legal residents will be eligible for
coverage through some program. The
issue is finding the appropriate program
and the appropriate level of subsidy.
Second, the income eligibility thresholds
will be determined through Modified
Adjusted Gross Income (MAGI) from tax
forms, at least for most applicants.
It should be noted that following
implementation of the ACA, as today,
most Americans will retain private,
employer-based coverage. In addition,
individuals age 65 and older will continue
to be covered by Medicare. While much
of the current coverage infrastructure will
remain in place, the ACA offers significant
new mechanisms and approaches to
publicly subsidized coverage, most
often for those who are low-income,
work in small businesses, or have health
conditions that made it difficult to
purchase affordable coverage.
In this section, we describe briefly the
current eligibility system for publicly
subsidized coverage and then the new
expanded coverage under the ACA.
The current pre-ACA eligibility
framework
Medi-Cal was established in 1965 as a
health benefit to people receiving welfare.
In the subsequent years, additional
Medi-Cal eligibility categories have been
created both to respond to the health
needs of growing numbers of uninsured
people as well as to address needs for
disabled and elderly people. Further,
additional categories have been added
aimed at covering select groups, such as
those in need of dialysis and those with
4
tuberculosis, breast cancer, or cervical
cancer.2 Each new category brings with it
eligibility rules that are slightly different
for many programs under the broad
umbrella of Medi-Cal.
In this current pre-ACA eligibility
framework, the process of determining
eligibility is designed to distinguish
between those individuals who can receive
coverage (and which type) and those
who cannot. Eligibility is determined for
the individual, and is based on income,
age and other characteristics indicating
disability or need. In California, children
and adults who qualify on the basis of
age, income, pregnancy and/or parenting
status make up the majority of MediCal beneficiaries (39 percent and 44
percent respectively), while persons
with disabilities represent 10 percent of
enrollees and seniors another 7 percent.2
Because Medi-Cal’s eligibility rules
historically have been linked to welfare,
some argue that Medi-Cal never had
its own guidelines, but borrowed from
eligibility criteria from the nation’s welfare
programs.2 However, over the years new
rules have been added, while at the same
time retaining aspects of the original
rules. This process has resulted in a long
and complex list of eligibility criteria
and eligibility codes—there are over 170
eligibility codes. Some of these eligibility
codes and the definitions are in Table 1.
An individual’s eligibility for many
of the Medi-Cal programs is based
on income, household compositions,
and assets (for some programs also
age categories). Importantly, the asset
test has been removed for programs
involving children. Income calculation
is not straightforward, but instead relies
on answers to questions about earned
income (e.g., wages), unearned income
(e.g., alimony or income from a parent or
child), and whether the income is assigned
only to the person receiving it or whether
it is partially allocated to a spouse or child.
Different calculations apply depending on
whether the income is received monthly,
quarterly, or annually and whether the
earner is disabled. Further, some income
is exempt (such as income from student
education loans) and not counted in
Medi-Cal income calculations.2 Similarly,
calculations of assets or property are not
straightforward. Like income, there are
items whose value is included in MediCal calculations and those that are not.2
As mentioned earlier, asset calculations
are part of eligibility for some, but not
all (there are no asset tests for children).
Some eligibility categories require sharing
of cost, whereas others do not. Eligibility
workers may place individuals in the
eligibility code program that is most
advantageous for them.
For children in both Medi-Cal and
Healthy Families (California’s State
Children’s Health Insurance Program or
CHIP) income is calculated as indicated
above, but then eligibility is based on
federal poverty levels (FPL) and the child’s
age, as follows. (The first three are for
Medi-Cal. Only the last one is for Healthy
Families.)
n
Infants up to 1 year in households
with incomes up to 200 percent of
Federal Policy Level (FPL),
n
Children aged 1 to 5 years up to 133
percent FPL, and
n
Children ages 6 to 19 years up to 100
percent FPL are eligible.
n
Uninsured children with incomes
above Medi-Cal eligibility levels but
below 250 percent FPL are eligible for
Healthy Families.
Adults in selected categories are currently
eligible if they meet income eligibility
qualifications. For example, pregnant
women with incomes up to 200 percent
FPL or parents with incomes up to 100
percent FPL are eligible. The elderly and
persons with disabilities qualify for MediCal by meeting the requirements for the
Table 1: Description of Medi-Cal programs
Medi-Cal Program
Program Description
Cash-related programs
CalWORKs
California Work Opportunity and Responsibility to Kids is California’s cash aid, welfare-to-work program for families
(California’s TANF program). California established CalWORKs to conform to the federal requirements that eliminated
Aid to Families with Dependent Children (AFDC) and established Temporary Assistance to Needy Families (TANF).
Families receiving CalWORKs checks are automatically eligible for Medi-Cal.
Supplemental Security
Income (SSI)
SSI is a cash payment program for elderly, blind and disabled. Those who receive SSI checks automatically receive
Medi-Cal.
Foster Care and Adoption
Assistance
Children who receive foster care checks are also eligible to receive Medi-Cal.
Refugee Medical
Some immigrants fleeing persecution from their homelands are classified by the U.S. Citizenship and Immigration
Service as refugees. Entrants and asylees may receive Refugee Medical Assistance (RMA) or Refugee Cash Assistance (RCA). Needy refugees, who meet the eligibility requirements for CalWORKs or the SSI program, receive
benefits under these programs as well as Medi-Cal coverage.
Assistance (RMA)/ Refugee
Cash Assistance
Section 1931(B) for families
Section 1931(b)
This category of coverage was created by Congress under Section 1931(b) of the Social Security Act to ensure
that needy families with children have access to Medi-Cal. Combining Food Stamps, AFDC (Aid to Families with
Dependent Children), and CalWORKs eligibility criteria in California, it was created to ensure that families eligible for
Medi-Cal under the old AFDC program would continue to be eligible for Medi-Cal after implementation of CalWORKs. States were also given the option to use “less restrictive” financial requirements to expand coverage to
more families, which California did.
Children’s programs
200% Program
This program provides Medi-Cal coverage for infants up to age 1 whose family income is at or below 200 percent
FPL. Infants born to a mother on Medi-Cal are automatically eligible for Medi-Cal for their first year.
133% Program
This program provides Medi-Cal coverage for all children from age 1 up to age 6 whose family income is at or below
133 percent FPL.
100% Program
This program provides Medi-Cal coverage for all children age 6 to 19 whose family income is at or below 100 percent FPL.
Other Medi-Cal programs
Pregnancy-related
Under Medi-Cal, pregnancy-related services are provided to encourage early and appropriate utilization of prenatal
care services. This program is available regardless of a woman’s immigration status, but is limited to pregnancyrelated services
Senior and Disabled
Seniors and persons with disabilities may qualify for Medi-Cal under one of several programs, such as aged/disabled
Federal Poverty Level program, Long-Term Care Program or others.
Medically Needy
Medically needy individuals are those who meet the SSI requirements for aged, blind or disabled (aged would not
apply for children) or the former AFDC requirements of deprivation, but do not receive cash assistance, usually
because their incomes are too high. Over 10 percent of adults are Medically Needy, but only a few children (approximately 2 percent). Those who receive Medically Needy Medi-Cal may be eligible with or without a “share of cost.”
Beneficiaries with no share of cost receive medical goods and services upon presentation of their Medi-Cal card. On
the other hand, beneficiaries with a share of cost must first incur the amount of the monthly share of cost for medical
expenses before Medi-Cal will pay for any medical goods or services.
Medically Indigent
This program offers Medi-Cal coverage to several very different groups of people. The financial eligibility criteria are
the same as those for the Medically Needy Program even if they don’t have dependent children and are not over 65,
disabled, or blind.
Transitional/Continuing
Medi-Cal Coverage
When people become ineligible for one Medi-Cal program, they often can qualify to receive Medi-Cal under another
program or through Transitional/continuing coverage. This program is designed to provide temporary coverage
for people who have lost cash assistance, continuing coverage for children, and procedural safeguards to ensure
continuing coverage.
Source: Kulkarni (2006) The Guide to Medi-Cal Programs Third edition.2 and Aid Codes Master Chart , (March 20123)
5
Supplemental Security Income (SSI) cash
assistance program for the elderly and
persons with disabilities. Eligibility for
the elderly and persons with disabilities
extends to 100 percent FPL. Some
individuals, who otherwise meet MediCal’s categorical eligibility criteria but
have higher incomes, qualify through the
“medically needy” pathway in Medi-Cal.
Individuals are eligible for the medically
needy program after incurring high
medical expenses that reduce their income.
To be eligible they must “spend down” into
Medicaid categories, which for individuals
is up to 83 percent FPL and for couples is
up to 97 percent FPL.
Because currently eligibility is for an
individual, some members of the family
can be covered and others not; and family
members who are covered can be split
among programs. For example, a family
with income at 200 percent FPL could have
an infant on Medi-Cal, an older child on
Healthy Families and parents uninsured or
have private coverage through an employer.
In other families, a mother could be
covered if she were pregnant, and otherwise
not. Depending on the household income,
children can be required to transfer to
Healthy Families at their first or sixth
birthday. Hence, it is currently possible,
even likely, that children and parents will
have different coverage types, and that
children will be split between Medi-Cal
and Healthy Families.
Undocumented immigrants and
other immigrants without satisfactory
immigration status who meet all other
Medi-Cal program requirements may
qualify for Restricted Medi-Cal, which
includes emergency services, pregnancyrelated services, kidney dialysis, and some
nursing home care. These services are
covered with state-only funds; federal
funds cannot be used for immigrants
without satisfactory immigrant status.
6
Importantly, under the current system,
childless adults who are too young for
Medicare (i.e., under age 65) generally
are not covered, unless they are eligible
through another mechanism (e.g.,
disability). This then is one of the largest
of the new groups that will receive coverage
under the ACA.
n
California version of CHIP known as
Healthy Families – Healthy Families
currently covers children whose
family income is above 138 percent
FPL for Medicaid and even up to
400 percent FPL. The ACA does not
change coverage categories for these
children. Congress chose to adopt a
“maintenance of effort” provision that
places penalties on states that reduce
their existing Medicaid and CHIP
eligibility for children prior to 2019.
Congress also extended federal funding
for CHIP though the end of fiscal
year 2015.4 Recent budget decisions in
California include a provision to fold
the Healthy Families program into
Medi-Cal. The impact of this change
in the short and long term is still to be
determined.
Eligibility framework
under the ACA: The
basic structure
Eligibility under the ACA has the potential
to be simpler than the current system.
The goal is to enroll all citizens and legal
residents in some form of coverage. In
general, for subsidized coverage, eligibility
rules will determine in which of three main
categories the individual or family will be
placed. This overall goal and approach is in
sharp contrast to the prior system. Rather
than determining who can and cannot
receive benefits, the system under the ACA
is designed to determine for which benefits
the individual or family is eligible. Further,
the ACA creates a new role of “Navigator”
to provide outreach and information to
consumers.
The three main categories of publicly
subsidized coverage under the ACA are:
n
Medicaid/Medi-Cal—Medi-Cal will
be expanded to include all citizens
and legal residents under age 65
with incomes up to 133 percent
FPL. This includes children, parents,
pregnant women, and adults without
dependent children. (In practice, using
the standard income disregard of 5
percent, the income cut-off will be 138
percent FPL) (Table 1). As is the case
currently, Medi-Cal recipients will not
pay premiums for coverage. Rather,
this coverage will be paid for through a
combination of state and federal funds
(Note that states have the option of
offering more generous coverage limits
for pregnant women).
State CHIP programs, including the
n
Subsidized coverage via the state
Health Insurance Exchange/ Health
Benefits Exchange—California was
the first state in the nation to create
an independent Health Insurance
Exchange through a law passed on
September 30, 2010, Assembly Bill
(AB) 1602 Chapter 6555 and Senate Bill
(SB) 900 Chapter 659.6 Individuals
earning between 133 percent (or 138
percent with disregards) and 400
percent FPL (approximately $29,000 to
$88,000 for a family of four in 2010)7
will receive subsidies for coverage, with
the amount of the subsidy declining
as income increases. The benefits for
Exchange plans will be determined by
the state, based on broad categories
of “essential benefits” defined by the
ACA. (Note: Exchange plans can also
be purchased without subsidies by
individuals and families earning more
400 percent FPL, if they do not have
other access to affordable coverage.)
The ACA also gives states the option to
create a Basic Health Plan, but they are
not required to do so.8 The Basic Health
Plan would cover certain citizens and
legal residents with incomes up to 200
percent of the FPL including those who
are ineligible for Medicaid (e.g., noncitizen, legal residents who have been in
the United States for less than five years9)
and those whose Medicaid coverage does
not include the essential health benefits
offered through Exchange plans. The ACA
requires that Basic Health Plan enrollees
receive the same or lower premiums they
would receive from an Exchange. 8,10 The
Basic Health Plan is intended, in part, to
decrease churning between Medicaid and
the Exchange plans.11
As noted above, Employer-Sponsored
Insurance (ESI) will continue to be the
primary source of coverage. The ACA
includes both additional requirements and
incentives (in the form of tax credits) for
employers to provide coverage.
n
The “pay or play” provisions of
the
ACA will require medium and large
employers to offer health insurance
coverage to full-time workers or pay
a penalty; further payment may be
required if coverage does not meet
affordability standards for low-income
workers.12
n
Federal small business tax credits are
available to small employers with no
more than 25 employees and average
annual wages of less than $50,000 that
purchase health insurance.13, 14
n
At state discretion, small businesses
with up to 100 employees qualify to
purchase coverage through the Small
Business Health Options Program
(SHOP Exchange).15 In California,
since Assembly Bill 1602 directs the
California Health Benefit Exchange
to establish a SHOP Exchange but
does not define “small employers,” it
is expected that the state will keep its
existing small-employer definition (up
to 50 employees) in place until 2016.16
Eligibility framework
under the ACA: Taxbased eligibility rules
covered through Medicare), persons with
disabilities, and those deemed eligible for
Medi-Cal from other programs. 18
Eligibility under the ACA is based on
Modified Adjusted Gross Income (MAGI)
from tax forms. Importantly, eligibility is
based on income and not income-plus-assets.
Because the MAGI system is very different
from the system currently in use, it will
change the eligibility process. In particular,
some families that formerly were not eligible
will be eligible, largely due to the elimination
of the asset test. A July 2011 report by the
Western Center for Law and Poverty, explains
the differences as follows17:
Subsidies, payments
and penalties
MAGI-based income counting rules
determine the household composition based
on whom the applicant can claim as a tax
dependent. This is different from the current
rules for determining a Medi-Cal ‘budget
unit.’ The application will have to ask the
relationship of the persons to each other
(as is currently done) and will now have a
checkbox or other indicator to show who is
a tax dependent for whom. The application
forms may be able to ask numerically (e.g.,
how many people, including yourself can
you claim on your taxes as a dependent?)
The new federal household rules will
shrink the household size for some families,
especially with split custody where the
custody arrangement determines who gets to
take the tax dependent status or alternates
between parents, or where there is a
caretaker relative who could count the child
as part of her household under Medi-Cal’s
old rules, but not as a tax dependent.
The end result is that although different,
overall eligibility determination will be
much simpler under the MAGI rules.
Importantly, there will be no asset test
for most people who apply for publicly
funded health coverage. Some individuals
will not be eligible for the MAGI program
and will be screened using the old rules.
These include seniors (since they are
Individuals and families eligible for MediCal will have no premiums or co-pays for
the program, while individuals eligible for
the Exchanges will receive a subsidy based
on level of income. The MAGI rules will
determine program eligibility and level
of subsidy, initially based on income for
the coming year – the year in which the
subsidies or other program support is in
place. The eligibility determination uses
both current income (from the tax form)
and an estimate of whether the income is
expected to change during the subsequent
year. Individuals will need to say whether
they expect their income to change over
the year. The subsidy to which they are
entitled will then be paid to the selected
managed care plan. The subsidy payment
is an upfront, one-time payment for the
entire year, to the health plan.
If income changes during the year, the
individual will need to notify the Exchange
of this change, and an adjustment in
premium/subsidy mix will be made.
If income increases, for example, the
individual will receive a lower subsidy and
will be required to pay a larger premium.
At the end of the year, there will be
a reconciliation –sometimes called a
“true-up” – of the subsidy. Repayments
will need to be made for the state’s
overpayment of subsidies. Individuals
who misestimated their income and
individuals whose income changed during
the course of the year will need to pay the
government for the overage. The payment
penalty could be very steep for families
and individuals in the income brackets
represented by the Exchange programs.
While repayment is capped at $600 for a
family at or below 200 percent FPL, $1,500
7
between 200 percent and 300 percent FPL,
and $2,500 between 300 percent and 400
percent FPL,19 many low-to moderateincome families would view these amounts
as difficult or impossible to afford in
already over stretched household budgets.
The risk of similar reconciliation has
been one reason why only 3 percent of
low-income workers who receive Earned
Income Tax Credits (EITC) claim those
credits during the year, in advance of filing
year-end returns.20,21 The risk of penalties
could have a deterring effect on families
and blunt their enthusiasm for subsidized
coverage.
Ensuring continuous
coverage
Enrolling in coverage is just the first step.
Coverage under Medicaid and through the
Exchange needs to be renewed annually,
in California as well as nationally.22
Thus, maintaining continuous coverage
at annual renewal is a second and
overridingly important step. Individuals
need stable, continuous coverage to reap
maximum benefits from health care
coverage. Studies conducted after passage
of the landmark SCHIP legislation when
coverage for children was dramatically
expanded, have documented the
importance of continuous, uninterrupted
coverage in improving access to care
and health outcomes. Specifically, these
studies have shown that children are
more likely to have a usual source of care
and less likely to have unmet needs than
uninsured children or children with onand-off coverage.23 Stable coverage allows
individuals to access regular care and
prevents catastrophic costs. Conversely,
unstable coverage –coverage with gaps
– leads to interruption of care, delayed
or missed appointments, and unfilled
prescriptions.
8
Stable, continuous coverage depends on
several factors. First, a smooth, simple
renewal process can help ensure that
coverage is retained if income or other
conditions have not changed. Secondly,
there needs to be an orderly, well working
process for moving individuals whose
circumstances do change into the program
for which they are then eligible.
Maintaining continuous coverage may be
especially challenging at major transition
points, when individuals may need to
move coverage programs, such as:
n
Child aging out of
There are a number of provisions in the
ACA to promote continuous coverage.
First, to promote a smooth renewal of
coverage, the Medicaid agency must do
an administrative renewal by evaluating
information from electronic databases.24
Individuals and families eligible for
CalFresh (California’s SNAP, formerly
Food Stamp Program) or CalWorks
(CaliforniaTANF) qualify for renewed
coverage based on information in these
databases and no further checking
would be needed. Secondly, renewal
forms will be pre–populated based on
current information in the databases and
mailed out to families.25 The Exchange
regulations state that the exchange must
send qualified health plan enrollees
an annual redetermination notice that
includes information on tax return and
household income, tax credit payments
and cost-sharing reductions in which
the enrollee is eligible.25-27 The Exchange
will re-determine eligibility based on the
signed and returned notice that includes
any corrections. If the form is not signed
and returned, the eligibility will be based
on the information provided on the
notice.25 If the information is still correct
and income is still within limits, coverage
will be maintained.
n
Foster youth aging out, and
n
Access for Infants and Mothers
n
Turning 65 years old,
n
Losing a job or losing hours in the job
(the whole family will be affected),
dependent status,
(AIM) enrollee reaching the 61st day
postpartum.
These points represent times of major
transitions, not only in life, but in eligibility
for MAGI-related insurance programs. For
example, individuals turning 65 years old
will move to Medicare from other types of
coverage. Losing a job or hours may involve
loss of employer-sponsored coverage and
a need to move into an Exchange Subsidy
program. Under the ACA, children can
stay on their parent’s employer-sponsored
coverage until age 26.15 After that time, they
will need to obtain their own coverage –
which could mean obtaining coverage from
an employer of their own or coverage in the
Exchange or Medicaid. Foster care youth
aging out of Medicaid and pregnant women
losing coverage after 60 days postpartum also
represent groups that will need to move from
one type of coverage to another. It should
be noted that these transition points occur
in the current framework as well and do not
go away with MAGI framework. However,
because they are a source of disruptions in
care they need to be highlighted.
What is the expected impact of the
ACA on population coverage?
The ACA will have a significant impact in
that all citizens will be eligible for some
form of coverage. The next sections show
expected growth in populations covered
by health insurance and then specifically
describes the impact on children.
Table 2: Preliminary estimates of insurance coverage by source for Californians under 65 years old (in millions)
for 2014, 2016 and 2019 - enhanced scenario.
Type of Coverage
Without ACA
(2014)
With ACA
(2014)
With ACA
(2016)
With ACA
(2019)
Employer-Sponsored
19.15
19.14
19.08
19.07
Medi-Cal
5.71
7.14
7.36
7.51
Healthy Families
0.78
0.63
0.66
0.67
Other Public Sources
1.22
1.22
1.24
1.26
Insurance Exchange (with subsidies for <400% FPL)
N/A
1.15
1.99
2.12
Individual market/Exchange without subsidies
2.21
1.70
2.03
2.15
Uninsured, eligible for coverage
4.58
2.71
1.77
1.99
Uninsured, undocumented
1.03
0.98
1.00
1.03
Table taken from a report by the UCLA Center for Health Policy and The UC Berkley Labor Center presented at the California Health Benefit Exchange Board on March 22, 2012. 28
Potential impact of
the ACA coverage
expansion for
Californians
In a presentation at the California
Health Benefit Exchange Board (HBEx)
meeting on March 22, 2012, projections
were described for insured Californians
based on a base scenario and an enhanced
scenario. 28 The enhanced scenario
assumes several factors that “should”
be in place based on current plans
including, a simplification of eligibility
determination, strong culturally and
linguistically appropriate outreach and
education, a “no wrong door” policy
to enrollment, the maximum use of
pre-enrollment strategies, an increase
in the take-up for Medi-Cal for both
newly and previously eligible, and a 70
percent take-up of uninsured into the
subsidized Exchange. It is projected that
the percentage of non-elderly Californians
who will have insurance in 2019 will be
84 percent without the ACA, 89 percent
with the ACA basic scenario, and 92
percent with the ACA enhanced scenario.28
Table 2 illustrates estimates of insurance
coverage based on the enhanced scenario.
Projections show that Medi-Cal is
expected to grow by over 2 million, largely
due to the newly-eligible adults, while the
Exchange is also expected to bring in over
2 million, even as employer-sponsored
coverage shrinks. In all, under the ACA
the number of eligible (but uninsured)
Californians is expected to shrink from 4.6
million to 2.0 million within five years.
Potential impact of the
ACA on coverage for
children
Under the ACA, even though already
eligible, children are also expected to
benefit from outreach and enrollment
efforts. For one thing, the overall
health and well-being of children may
also depend on the extent to which the
mental and physical health needs of their
parents are being addressed. However,
beyond this benefit for children, based
on their parents having coverage, more
specific enhancements in coverage are
also expected. The national experience
of enrolling the newly-eligible CHIP
population after enactment of SCHIP
legislation in 1997 offers insights for what
might occur with enrollment efforts after
the ACA. Advertising and community
outreach centered on enrollment in
CHIP, and brought in not only newlyeligible children, but also children who
were eligible at the time for Medicaid,
but not enrolled. In fact, nationally
more Medicaid than CHIP children were
enrolled during this time.29
Likewise, enrollment efforts aimed at
childless, non-disabled adults under
Bridge to Reform, and subsequently the
ACA, are likely to result in increased
enrollment for children. Research has
shown that children are more likely to have
coverage if their parents are insured.30-33
Currently, approximately two-thirds of
uninsured children in California – as well
as nationally – are eligible for coverage,
through either Medicaid or CHIP. These
children are likely to be touched by
outreach efforts. In fact, analysts predict
that the single most important way that
children will gain coverage under health
reform is likely to be through increases
in coverage in Medicaid and CHIP
enrollment among children who are
already eligible.33
National impact if
“Maintenance of Effort”
for Medicaid and CHIP is
rolled back
National estimates show that the ACA
has the potential to reduce the number
of uninsured children by 40 percent
and uninsured parents by almost 50
percent.32 Achieving reductions of this
magnitude requires states to adhere to the
“maintenance of effort” provisions in the
ACA, a requirement some budget-strapped
states are trying to roll back.
If Medicaid and CHIP coverage were allowed
9
to lapse, some of the children would receive
Exchange subsidy coverage. However, children
whose parents had access to employersponsored coverage would not be eligible for
coverage in the Exchanges. The cost to families
of securing employer-sponsored coverage for
their children would be markedly higher than
enrolling in Medicaid or CHIP.32 This, in turn,
would increase the risk that the children would
go without coverage, despite the penalty for
doing so.
CalHEERS will be the single point of entry
for enrolling individuals and families in
coverage in the following three programs,
using the new MAGI enrollment rules:
6) Enables real-time and accurate
eligibility determinations
n Healthy Families: Through CalHEERS
8) Ensures no gaps in coverage
as an enrollment portal, parents in low
income families can access the Healthy
Families program in order to purchase
subsidized health care for their children.
n California Health Benefit Exchange:
It is estimated that by 2016, 2 million
California residents will enroll in health
care plans through which the federal
government will subsidize cost sharing and
a portion of their premiums. In order to
find the best health care plan, CalHEERS
provides a mode for individuals not
eligible for subsidies to comparison shop.
Additionally, CalHEERS will provide a
Small Employer Health Options Program
(SHOP) allowing small business owners
and employees to choose fitting health
care plans.
What systems are being
put in place at the state
and county levels to
determine eligibility and
to facilitate enrollment?
California Healthcare Eligibility,
Enrollment and Retention System
(CalHEERS)
The California Health Benefit Exchange
(HBEx), California Department of Health
Care Services (DHCS), and Managed
Risk Medical Insurance Board (MRMIB),
collectively serving as Sponsoring Partners,
are building the California Healthcare
Eligibility, Enrollment and Retention
System (CalHEERS), an information
technology (IT) system to support for
eligibility, enrollment, and retention in
health coverage.34 This system will:
n
Provide eligibility information about
affordable coverage,
n
Enroll eligible individuals and families
and provide access to federal subsidies,
n Offer health plan choice information, and
n
Support access by small employers to
health plans for their employees.35
On October 1, 2013, CalHEERS Web portal
will “go live” and provide a “one-stop shop”
for eligibility determination, and by 2016 will
enroll 4.4 million California residents.35, 36
Coverage for eligible persons can begin as
early as January 2014.
n
Medi-Cal: By creating easier access
to obtain Medi-Cal coverage with
streamlined eligibility rules, CalHEERS
will increase full health care coverage
access for an estimated 1.7 million
newly eligible by 2016.35
The CALHEERS system is based on design
principles crafted to be responsive to the
nine important essential program goals
developed in the Exchange Board.34 The
California Healthcare Eligibility, Enrollment
and Retention System Proposed Essential
Program Goals are:
1) “No Wrong Door” service system that
provides consistent consumer experiences
for all entry points
2) Culturally and linguistically appropriate
oral and written communication which
also ensure access for persons with
disabilities
3) Seamless and timely transition between
health programs
4) Reduction in consumer burden of
establishing and maintaining eligibility
5) Ensured security and privacy of
consumers
10
7) Ensures transparency and
accountability
9) Enables consumers to make informed
choices
The “no wrong door” principle means
that consumers can apply using a variety
of means, including directly accessing the
portal, mailing in applications, applying
face to face, or using a toll-free hotline, as
shown below.
As shown in Figure 1, no matter which
“door” is used, information in the
applications will be put into the MAGI rules
engine, if it has not been entered directly
through the Web portal. Key functions of
CalHEERS are included in Box 2.34
Interfaces and integration between
CalHEERS and other data systems
Ultimately, CalHEERS will interface with
large databases at the state and federal levels
that contain tax information, wage reporting
data, and possibly information from other
support programs. These sources may be used
to verify a person’s eligibility and will assist
the system in identifying the type of coverage
for which the applicant qualifies. At the
federal level, CALHEERS will interface with
such databases as: Internal Revenue Service,
Department of Homeland Security, and Social
Security Administration, all of which will
be part of a federal Data Services hub.36 At
the state level, CALHEERS will also interface
with multiple state data sources such as the
Medi-Cal Eligibility Data System (MEDS) (for
online, real-time verification of applicant’s
current enrollment status in any health
coverage program in California), Employment
Development Department (to verify state
employer identification number and other
appropriate information), insurance carriers
(to receive health plan information) and
financial institutions (for issuance of payment
and receipt of payment information).36
Figure 1: “No Wrong Door”: Consumer may apply using four mechanisms
System described in the “Announcement of Intent to Award California Healthcare Eligibility,
Enrollment & Retention System (CalHEERS) Contract to Accenture” released on May 31, 2012. 35
Consumer
Consumer
Mailing Address
Face-to-Face Service
Mail
Processors
Consumer
Consumer
Toll-Free Hotline
Counties, Providers
Navigators, Brokers
Service Representatives
Web portal
IT Infrastructure
Figure taken from “The California Health Board Exchange: Design Options” discussed at the September 27, 2011 California Health Insurance
Exchange Board Meeting37
A critical interface with the State
Automated Welfare System (SAWS), which
is used for determining eligibility in nonMAGI Medi-Cal and a number of social
services programs, such as CalWORKs
and Cal-Fresh. Individuals not eligible
for MAGI programs can be passed to
the SAWS system for determination of
eligibility not only for health insurance
(non-MAGI), but also for eligibility in
other social service programs. Providing
this functionality, and interfacing with
human services presents enormous
opportunities to improve coverage in both
health care and other human services.
Some policymakers have suggested that
states consider using MAGI to determine
eligibility under both the ACA and other
human services programs, so that all have
Box 2: What key functions will the California Healthcare Eligibility,
Enrollment and Retention System have?34
Functionality for eligibility determination, enrollment, and renewal, including:
o Single rules engine for MAGI‐related eligibility determination
o Coordination with county Statewide Automated Welfare System (SAWS) systems for
non‐MAGI eligibility determination
o Single application
o On‐line verification
o Support for selecting among offered health plans, such as:
l Identification
l Premium
of qualified health plans as bronze, silver, gold, or platinum levels
and cost sharing information, including available subsidies
l Results
of enrollee satisfaction survey
l Quality
ratings
l Medical
loss ratio information
l Provider
directories
Functionality for plan management, including certification of issuers
Functionality for financial management, including data collection and accounting processes
Functionality for consumer assistance online, over the phone, and by mail
Online support for service and financial transactions for those assisting in enrolling consumers (e.g., Navigators or Agents)
Source: Kulkarni (2006) The Guide to Medi-Cal Programs Third edition.2 and Aid Codes Master Chart , March 20123
the same eligibility determination rules.17
However, this is a change for the future. In
the short run, families, eligibility workers,
and policymakers will need to work within
two sets of rules – one for health care
coverage for most people and another for
other human services. Nevertheless, even
before adoption of common eligibility
rules, there are many steps that human
services agencies can take to maximize
enrollment in health care; conversely, there
are many ways in which the process of
applying for health insurance can be used
to maximize human service enrollment.
Human services processes can be used to
maximize enrollment in health care by,
for example, ensuring that county human
services offices remain a point of entry
for applicants for health insurance, as
California is doing. Secondly, counties
can use human services data to identify
individuals who are highly likely to be
newly eligible for Medi-Cal and can provide
targeted outreach to these individuals. For
example, many childless individuals are
known to the counties because of their
participation in Cal-Fresh. Third, data
from human services programs can be used
to help determine eligibility for Medi-Cal,
Healthy Families and Exchange subsidies.
Cal-Fresh and school meal programs are
likely to have current, verified information
about household composition and income.
Further, this information could be useful
in updating the status of individuals and
families whose circumstances have changed
since the last tax return.
Conversely, counties can use the ACA
outreach and enrollment process to
maximize enrollment in human services
programs. Publicity around the ACA could
be used to draw attention to the availability
of other public benefit programs, and then
the full range of application systems could be
used to support human services enrollment.
Although eligibility rules are different, data
collected as part of the process of enrolling
in health coverage could then be used as the
core of the application for human services
programs. Thus, the planning calls for the
11
user-friendly platform for health insurance
coverage can be used as the first step in
assuring that individuals and families receive
all the benefits for which they are eligible.
It should be noted that although the MAGI
eligibility rules are simpler than the current
eligibility rules, the task of assisting clients “on
the ground” may be more complex, because
clients may be eligible for either MAGI
or non-MAGI programs. Further, clients
may also be eligible for other social services
programs. There is a substantial cadre of
Certified Application Assistants (CAAs) in
communities throughout the state38 who are
available for in-person assistance. However,
some training may be necessary to bring
them up to the task. Counties already know
and use the non-MAGI screening rules; and
interface with the counties may be necessary.
What are some issues/
special concerns for
the next stages of
implementation?
While the broad outlines for
implementation are coming into place,
and while overall the ACA will usher in
a much broader and simpler program,
there are some issues of which to take
note. First of all, much emphasis has been
placed on systems for initial enrollment.
As is currently the case, attention will
also need to be placed on renewal, to
ensure that individuals have continuous
uninterrupted coverage. Secondly, while
the current system has provisions for
interfacing with state and local databases,
even more reliance on large databases
may be necessary to ensure going to scale
rapidly. Finally, continued focus will be
needed on ensuring coverage in families
with complex eligibility situations.
Attention on coverage renewal
Coverage for MAGI eligible beneficiaries
in Medi-Cal and the state health insurance
Exchanges last for one year, at which time
12
individuals and families need to demonstrate
continued eligibility for subsidized coverage
and renew coverage in the same program
or different program (if income or other
circumstances change). Employer-sponsored
coverage will extend, as it does now, as long
as the employer policy is in place, with no
requirement for annual eligibility checks.
It will be important to monitor
continuity of coverage to make certain
that policies are in place to ensure stable
coverage, especially through some of the
transitions mentioned earlier. It will also
be important to monitor continuity of
coverage for children in the current CHIP
program, especially if maintenance of
effort is not upheld at the federal level.
Dropping coverage could be an indicator
of lack of affordability or of other policy
decisions. For example, analysts and
advocates have raised concerns that
families may find premiums unaffordable,
even with subsidies, and may forego
coverage from time to time.32
The Children’s Health Insurance Program
Reauthorization Act (CHIPRA) legislation
requires states to monitor coverage for
Medicaid and CHIP children, and practices
established under CHIPRA need to be
continued after implementation of the ACA.
Figure 2 shows that in recent years there
has been a steep drop-off under the
current system at the 12-month renewal
point for both Medi-Cal and Healthy
Families.23 The drop-off begins at the
12-month renewal point and by 21 months
only about 50 percent of the children in
each program remain covered.
Despite a simplified procedure, under
the ACA, testing will need to be done not
only to determine eligibility for Medi-Cal
(i.e., whether the MAGI puts the family
or individual below the 138 percent FPL
eligibility level for Medi-Cal) and eligibility
for subsidies under the Exchange (i.e.,
whether the income is between 138 percent
and 400 percent FPL), but also to determine
where the MAGI-determined income falls
within the Exchange range to determine
for what level of subsidy the family is
eligible. Thus, there is likely to be more
means testing in the eligibility system under
the ACA. Moreover, even though renewal
is simplified and all citizens and legal
residents will be eligible for some program,
there may be slippage at transition points.
Optimal use of large data systems
at the state and federal levels
The ACA requires that to the “maximum
extent practicable,” all subsidy programs
must establish, verify, and update
eligibility for participation in the program
using “data-matching arrangements
and determine eligibility on the basis of
reliable third party data.”39 Policymakers
and analysts have argued strongly that
states will need to use information in
large data systems, such as the verification
systems described above, to reach eligible
populations and to ensure coverage
continuity. An Urban Institute analyst, for
example, cites compelling evidence that
use of large data bases with income and
other eligibility-related information will
be necessary for the ACA to come to scale
as rapidly as envisioned.40
n
When Massachusetts implemented
its 2006 health reform legislation, the
state used data matches with its preexisting “free care pool,” without the
need to file applications. After nine
months of program operation, more
than 80 percent of enrollees into the
state’s new subsidy program qualified
based on these data matches.40,41
n In contrast, many federal and state
programs without such proactive, datadriven enrollment strategies have fallen
significantly short of their goals. Even
CHIP, which now covers 82 percent
of eligible children,42 took a long
time to achieve these results. Despite
Figure 2: Drop-off in coverage at annual renewal in California
find it more affordable to accept employersponsored coverage for parents, while
enrolling children in public coverage.
Percent of Children Still Enrolled
100%
Healthy Fam
MediCal
80%
60%
52
51
40%
0
3
6
9
12
Months After Initial Enrollment
15
18
Figure taken from Fairbrother G, Schuchter J. Stability and Churning in Medi-Cal and Healthy Families. The California Endowment; March
2008.23 Medi-Cal data are from July 2003 through June 2005; Healthy Families data are from January 2004-December 2005.
considerable outreach and streamlining
of applications during the program’s
start-up phase, only 60 percent of
eligible children fully participated in
CHIP five years into the program.43
This caused the Congressional Research
Service to observe that “… there was
general disappointment with the
implementation progress under SCHIP,
due to the low enrollment rates early in
the program.” 44
Analysts have emphasized strongly
that it will not be effective to trust that,
“armed with good information, faced
with a requirement to obtain coverage
and given options for easy enrollment,
tens of millions of uninsured will rapidly
come forward on their own and obtain
health insurance.”40 Instead, a proactive,
data-driven enrollment strategy will be
needed to come to scale. The fact that
the eligibility system under the ACA is
tax-based invites the possibility of using
tax returns ultimately to identify eligible
individuals and enroll them as part of the
tax filing process (Box 3).
Ensuring coverage in families with
complex eligibility situations
Although the ACA will simplify coverage
for most families, this may not be the case
for certain families with complex eligibility
situations. These families include:
children who have at least one parent
from whom they live apart; children
eligible for Medi-Cal/Healthy Families,
while their parents are eligible for the
Exchange; and children eligible for MediCal/Healthy Families whose parents have
either employer sponsored coverage or are
undocumented and thus do not qualify
for ACA coverage.46 Nationally, estimates
show that approximately 20 million
children in the United States will be in
these families with complex eligibility
situations.46 A comparable number for
California is unknown, but it is clear that
the number will not be trivial. Further,
in California, the complexity involving
families of undocumented parents with
citizen children will be especially acute.
Some families have no alternative to
splitting coverage because of differences
in eligibility, while others may have a
choice. For example, families may choose
to enroll eligible children in Medi-Cal/
Healthy Families because of the more
robust benefits, while enrolling in the
Exchange themselves. Other families may
Addressing the needs of these families
with complex eligibility situations will
be essential to ensuring coverage for all
family members. These families may also
face additional challenges in obtaining
care once enrolled. It may be the case
that insurance companies, and possibly
provider networks will be different for
different family members. This will mean
that the family will need to navigate more
than one insurance system and possibly
deal with multiple providers. Undocumented immigrants not
eligible under the ACA
Under the ACA, in most cases
undocumented immigrants will continue
to be ineligible for Medi-Cal coverage using
federal funds (emergency care and labor
and delivery are two exceptions), and will
not be eligible for federal subsidies in the
Exchange. However, state funds could
continue to be used to subsidize selected
benefits for undocumented individuals, as
they are now. In addition to being ineligible
for federal funding under public programs,
the new health care law explicitly excludes
undocumented immigrants from purchasing
individual coverage through the new
insurance exchanges, either at full cost or
with a tax credit. Other family members
in the same family, who are citizens or have
documentation showing legal status can buy
insurance and receive a tax credit.47
The state currently funds insurance
programs for undocumented children,
but with the budget crisis, some observers
believe that this may not continue. In
addition to the undocumented children
who are ineligible, other citizen children
of immigrant parents may be excluded
if their parents failed to enroll them due
to confusion around the new system
and misunderstanding of the eligibility
requirements. An estimated 180,000 to
200,000 undocumented children could
13
Box 3: Potential for further simplification: Use of tax returns
An estimated 86 percent of uninsured Americans file federal income
tax returns. Even among the uninsured with incomes below the federal
poverty level, fully 75 percent file income tax returns.40 The ACA specifically
authorizes Health and Human Services to permit consumers to apply for
subsidies, – i.e., consumers can “request the Secretary of the Treasury to
provide [tax return] information directly to the Exchange.”45 If this approach
were to be used, community and other efforts could help assure coverage
by assisting low-income individuals with their tax returns.
be uninsured as a consequence of the
combined direct and potential indirect
effects,48 and would need to rely on the
safety net for care.
California’s safety net institutions –
community health clinics and public
hospitals – are likely to serve a significant
number of adults as well as children, and
this will raise significant capacity issues for
the safety net broadly. The newly insured
patients are likely to seek care in the safety
net institutions. These institutions are
preparing for the expected influx through
a Delivery System Reform Initiative to
strengthen care delivered through the entire
system and make higher quality care more
accessible and efficient.49 Still, the impact of
the expected influx, including newly insured
adults plus uninsured immigrant children
will be significant.
How can eligibility and
enrollment be maximized
and made most efficient
at the local/community
level?
The ACA offers important challenges and
opportunities for enrolling newly eligible
individuals and currently eligible-but-notenrolled individuals (most of these are
children) into health coverage. The goal
of going to scale quickly – that is, enrolling
virtually all eligible individuals in a relatively
short time – and keeping them enrolled
requires effort at the local level and policies
at the state and national level that support
this effort. Some steps to this end include:
14
Set up systems for in-person
application and enrollment assistance
at the community level in order
to make enrollment processes as
accessible as possible.
The ACA establishes “Navigators” to help
with enrollment and access. There is already
a robust network of consumer advocates in
place for enrollment assistance.17, 38 These
community advocates can be trained to assist
with enrollment and renewal in health and
other services. These workers will need to be
trained in using the new MAGI rules, as well
as maintaining proficiency in applying the
current rules because some individuals (i.e.,
seniors, and persons with disabilities) will be
screened using the old rules.
Focus on families and children with
complex eligibility situations and
families at difficult transition points,
to ensure that high-need families do
not lose coverage because of their
situations.
The new MAGI rules will be simpler for most
families, but some families have complex
circumstances and may require additional
attention. These include families in which
parents live apart from the children or families
with split coverage. This also includes families
or individuals at transition points, who may be
moving from one type of coverage to another.
For example, a family member losing a job or
losing hours – or conversely gaining a job or
working more hours – would usually mean a
transition to another form of coverage or at
least a different level of subsidy. There is a need
for community-based Navigators and county
eligibility workers to assist these families with
complex eligibility situations.
The cadre of community workers should
take on a special focus with immigrant
families to ensure that the family members
who are eligible have coverage and the
others know of safety net sources of care.
Any confusion and misunderstanding
around implementation is likely to be
especially acute in families with mixed
immigration status.
Set up systems to monitor coverage
continuity.
States and counties need to set up systems
to monitor coverage continuity (as is now
required in CHIPRA) to show the effect of
policies on enabling continuous coverage
under the ACA. In the past, monitoring of
continuity has provided valuable data for
assessing the effects of policies, such as changes
in continuous eligibility periods, changes
in premiums, and others. While all citizens
will be eligible for some form of coverage,
and although there are penalties for forgoing
coverage, breaks in coverage still may occur.
There will still be means testing at renewal
points for families and individuals receiving
subsidies, and even though the renewal process
has been simplified, this is traditionally a point
at which families lose coverage.
Furthermore, families may find coverage
unaffordable for themselves or their
children and fail to enroll. Coverage
continuity overall and for particular groups
is an important barometer for effectiveness
of enrollment policies. To be optimally
useful, continuity needs to be reported at
least at the state and county levels. Ideally,
information on continuity of coverage
would also be available to the sub-county
level, and would be used to guide outreach.
Ensure that the platform for
enrollment into health insurance
coverage also serves as a platform
for enrollment into other needed
social services.
It will be important to use the new userfriendly system for enrollment in health
reform as a platform for enrolling in other
social services. This action will extend the
“culture of coverage” concept beyond health
insurance to all benefits to which a family
or individual is entitled.
Publicity and outreach around the ACA
should be used to draw attention to
other human services programs operated
by counties, schools and other entities
(Cal-Fresh, the Woman, Infants and
Children -WIC- program, and school meal
programs, for example). Data collected
as part of the ACA application should be
used to populate the application for other
services; the application process then
would only need to ask for supplemental
information.
Human services databases, in turn, should
be used to the maximum extent possible
to support enrollment under the ACA,
for example by identifying individuals
potentially eligible for health coverage, and
making use of the fact that these databases
may have recently-verified information
that is more current than information on
the tax form.
Ultimately, to achieve maximum
integration, eligibility rules for social
services will need to be modified so that
they conform to the MAGI rules for health
care coverage.
The Road Ahead:
Realizing the Promise of
Health Care Reform
With the recent Supreme Court opinion50
upholding most of the ACA, the nation
will move forward with implementation.
The proactive steps the state of California
took in securing its “Bridge to Reform”
waiver, establishing Insurance Exchange,
and designing the technology to support
eligibility and enrollment under the ACA
will mean that implementation can move
at an accelerated pace. The opportunities
in the ACA are enormous. It has the
potential for creating a “Culture of
Coverage” in which health care coverage
is viewed as a right. The user-friendly
platform for determining health care
coverage can also be used as a gateway
to other social support programs. These
great opportunities in the ACA can best
be realized through active engagement,
ongoing monitoring and continuous
quality improvement efforts by wellinformed consumers, advocates, and
clinical and service providers.
About the Authors
Gerry Fairbrother, Ph.D. is a Senior
Scholar at AcademyHealth. She is an
experienced health services researcher and
epidemiologist, with a special focus on
access to and quality of care for vulnerable
populations, provider incentives to
promote quality of care, vaccine policies
and information technology. Dr.
Fairbrother is a current member of
an Institute of Medicine Committee
on Assessment of Studies of Health
Outcomes Related to the Recommended
Childhood Immunization Schedule
and a member of Centers for Medicare
and Medicaid Services Technical Expert
Panel on National Impact Assessment of
CMS Quality Measures. Before coming
to Academy Health, she was a professor
of pediatrics at Cincinnati Children’s
Hospital Medical Center, where she also
served as the Associate Director of the
Child Policy Research Center. While in
Ohio, she received the 2006 “Best Ohio
Health Policy Award” from the Health
Policy Institute of Ohio. She is a Fellow
in the New York Academy of Medicine,
a Fellow of the Academic Pediatric
Association, a member of the National
Academy of Social Insurance and is on
the National Policy Advisory Committee
of the National Institute of Children’s
Healthcare Quality.
Tara Trudnak, Ph.D. is a Senior Research
Associate at AcademyHealth. Dr.
Trudnak’s research areas include
evaluation of quality improvement,
prenatal care programs, pregnancy
outcomes, Latino health, obesity, chronic
disease, smoking cessation, mobile health,
and health program evaluation. Her
current research focused on evaluation
of health care quality improvement
initiatives.
The authors wish to thank Amy Fine
and Frank Farrow for their review and
comments on this brief and for their help
and inspiration in conceptualizing the
project. They would also like to thank
Isabel Friedenzohn and Cathy SenderlingMcDonald for reviewing this paper.
About this Brief
This brief is one in a series exploring
health reform implementation
opportunities for place-based initiatives
(PBIs). It is part of a broader project
at the Center for Study of Social Policy
that explores how PBIs can advance
implementation of health reform and
how health reform implementation
can further the work of PBIs. The
California Endowment and its partner,
the Community Clinics Initiative, have
provided generous funding for this project.
The Center for the Study of Social Policy
(CSSP) seeks to secure equal opportunities
and better futures for all children and
families, especially those most often
left behind. Based in Washington, DC,
with strong ties to communities and
policymakers nationwide, the Center’s
work focuses on three broad areas: system
reform, public policy and community
change. Underlying all of CSSP’s work is a
strong commitment to racial equality.
AcademyHealth represents a broad
community of people with an interest
in and commitment to using health
services research to improve health care.
AcademyHealth promotes interaction
across the health research and policy
arenas by bringing together a broad
spectrum of players to share their
perspectives, learn from each other, and
strengthen their working relationships.
15
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