California’s Experience:
Designing a Streamlined
User-Friendly Enrollment System
January 19, 2012
Kristen Golden Testa
Health Director
The Children’s Partnership
Families USA Conference
Washington DC
Overview
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California Experience
 What we have to work from
 Partnering agencies/governance
 State legislation
 Draft design
 Stakeholder input
 RFP
TCP’s Enrollment roadmap
Lessons Learned
www.childrenspartnership.org
What California Has Now
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58 counties determine Medicaid eligibility
3 county Medicaid IT systems
1 private vendor for centralized CHIP eligibility
A “single point of entry” for joint applications
Health e app
Express Lane for pilot school lunch programs
Separate Exchange board up and running
www.childrenspartnership.org
What California Has Now
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Negative: Previous attempts to
consolidate/privatize/centralize left mistrust
Negative: Enormous structural budget deficit
Positive: ACA requirements and new federal
funding in the short term
Positive: Strong political energy and talent
behind the California Health Benefit Exchange
(HBEX)
www.childrenspartnership.org
California Experience: Governance
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DHCS and counties for Medicaid (Medi-Cal)
CHHSA (overseeing Medicaid and CHIP)
MRMIB for CHIP (Healthy Families)
New California Health Benefits Exchange
(HBEX)
??? Who is ultimately responsible for the
California Health Eligibility, Enrollment and
Retention System (CalHEERS)
www.childrenspartnership.org
California Experience:
State Legislation
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AB 1296 (2011) creates CalHEERS to:
 Streamline eligibility rules among Medi-Cal, premium
subsidies in the Exchange, and Healthy Families;
 Coordinate and simplify citizenship and identity verification at
application and renewal;
 Require a single statewide application used at all entry points;
 Adopt rules for “no wrong door” to ensure consistent
determinations from one system
 Require real-time determination
 Establish consumer protections and transparency
requirements
Establishes stakeholder planning and design process
www.childrenspartnership.org
Enrollment IT Design
California Experience:
Stakeholder Process
 Advocates’
own coalition
 Slow agency coordination
 HBEX stakeholder workgroups
 HBEX state tour: input on marketing,
enrollment and retention
 Joint agency process
www.childrenspartnership.org
California IT RFP Goals
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“No Wrong Door” service system with consistent
consumer experience through all entry points
Culturally and linguistically appropriate oral and written
communications , access for persons with disabilities
Seamless and timely transition among health programs
Minimal eligibility burden for consumers
Security and privacy of consumer information
Real-time eligibility determination
Transparency and accountability
No gaps in coverage
Consumers to make informed choices
California RFP Functionality
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Single rules engine for MAGI‐related eligibility determination
Coordination with county systems for non‐MAGI eligibility
Single application
On‐line verification
Support for selecting among offered health plans, such as
qualified health plans levels, premium/cost sharing ,enrollee
satisfaction survey, quality ratings, medical loss ratio
information, and provider directories
ƒPlan management, including certification of issuers
ƒFinancial management,
ƒConsumer assistance online, over the phone, and by mail
ƒOn‐line support and financial transactions for navigators
Our Enrollment Roadmap
1. Smart connections through multiple doorways
and accessible consumer assistance.
2. Integrated eligibility criteria and processes
across programs.
3. Real-time, immediate, and ongoing
enrollment.
4. Easy navigation of coverage
www.childrenspartnership.org
Roadmap: Multiple doorways
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Target harder-to-reach populations who need live
connections and assistance
Consumer assistance and call center provide realtime (either automated and live human) assistance
Web portal to support the full coverage experience
Use express lane strategies and technology to
prepare for large-scale pre-enrollment.
Leverage enrollment gateways to reach more
uninsured consumers
www.childrenspartnership.org
Roadmap: Integrated Process
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Single shared eligibility system for all insurance
programs, regardless of program entry point
Conform income and other eligibility criteria
Continue essential health services and coverage
pathways with insurance program
Integrate eligibility and enrollment for other human
service programs
www.childrenspartnership.org
Roadmap: Real-time Enrollment
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Modernized IT system and state verification hub
Data hierarchy to resolve inconsistencies in
eligibility data to reduces need for follow-up
When real-time not possible, provide immediate
coverage to eligible consumers
Establish consumer-protection policies to govern
the use of data
www.childrenspartnership.org
Roadmap: Easy Navigation
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Enrollment UX project
Integrated health plan enrollment with eligibility
process and real-time
Coordinated premium payment across programs
Consumer-friendly procedures for those facing
changing circumstances
Easy navigation through multiple programs for
mixed-coverage families
Connecting employees/dependents of SHOP
employers with Exchange subsidies, if eligible
www.childrenspartnership.org
California Lessons Learned
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Stakeholder input and coordination
Clear governance
Thinking through the details
Don’t forget SHOP as linkage opportunity
Best practices from other states (and UX
project)
Federally funding essential
www.childrenspartnership.org
Contact
Kristen Golden Testa
(415) 505 1332
ktesta@childrenspartnership.org
www.childrenspartnership.org
For CA HBEX information:
www.hbex.ca.gov