The California Health Benefit Exchange: Eligibility and Enrollment Design Options

Stakeholder Workgroups Meeting

In-person/Webinar eventThursday, September 15, 2011

Welcome

3 3

Partners

Thanks to our partners:

Department of Health Care Services (DHCS)California Health and Human Services Agency (CHHS)Managed Risk Medical Insurance Board (MRMIB)Office of Systems Integration (OSI)

Introductions

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Summary of Key Stakeholder Input

Build confidence and trust through reliable process at launch

Consumers control the use of their personal information

Consider the perspective of all consumers

Enable live contact at all points of enrollment process

Provide status updates during eligibility process

Apply rules consistently regardless of method of entry

Small Business Health Options Program (SHOP) must bring value tothe marketplace, employers and brokers

6

How Stakeholder Input is Utilized

Inform design optionsInform system usability requirementsInform Notice of Proposed Rule Making (NPRM) commentsStructure ongoing workgroup meetings

7

Objective of Today’s Meeting

To obtain stakeholder feedback on design options related to eligibility and enrollment processes

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Eligibility and Enrollment Principles

“No Wrong Door” service systemCulturally and linguistically appropriate oral and written communicationsSeamless transition between health programsReductions in the burden of establishing and maintaining eligibilitySecurity and privacy of consumer information

9

Decision Criteria

Does the option comply with federal and state requirements?Does the option provide a feasible solution to be operational by 2014?Does the option provide a first class customer service experience?What are the cost considerations, most notably ongoing operational costs? Are current assets being leveraged? Is the option efficient? Are there redundancies?What risks are associated with the option?

Mail 

Processors

Consumer

Counties, 

Navigators, Brokers

Service 

Representatives

IT INFRASTRUCTURE

Mailing addressMailing address Face‐to‐Face 

Service

Face‐to‐Face 

Service

Toll‐free hotlineToll‐free hotline

ConsumerConsumerConsumer

Web‐PortalWeb‐Portal Web‐PortalWeb‐Portal Web‐PortalWeb‐Portal

Web‐PortalWeb‐Portal

Consumer View

11

IT Infrastructure Framework

Types of consumers:Individuals receiving subsidiesIndividuals not receiving subsidiesEmployers/ees (SHOP eligible)MAGI Medi-Cal eligible peopleNon-MAGI Medi-Cal people Children eligible for Healthy FamiliesPotentially Basic Health Program eligible people (TBD)

*MAGI: Modified Adjusted Gross Income

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IT Infrastructure Framework

Key Required IT Functions:

WebsiteEligibility determination for: Exchange subsidies, SHOP, MAGI Medi-Cal, Non-MAGI Medi-Cal, CHIP, Basic Health PlanShop/compare/plan selection functionality for: Exchange subsidies, SHOP, MAGI Medi-Cal, Non-MAGI Medi-Cal, CHIP, Basic Health Plan Case maintenanceMaintain master client indexRetrieve information to support service callsReferrals to other human services programs: CalFresh, TANF, etc.

Central IT Infrastructure (CITI)

•Provide website offering ACA required functions• Determine eligibility for all types of coverage• Deliver eligibility determination results to applicant •Provide online shop/compare/plan selection functionality for all

applicable health programs• Store all cases centrally for ongoing case maintenance•Retrieve information to support service calls

Service 

Center

Respond to 

consumer 

calls

Process mail

Service 

Center

Respond to 

consumer 

calls

Process mail

Face‐to‐Face ServiceCounties, Navigators, Brokers

Face‐to‐Face ServiceCounties, Navigators, Brokers

Federal Long‐Term Vision

Central IT Infrastructure (CITI)• Provide website offering ACA required functions• Determine eligibility for Exchange subsidies and employee coverage• Obtain eligibility determination for MAGI and non‐MAGI Medi‐Cal from 

appropriate County SAWS system• Obtain eligibility determination for CHIP from MRMIB system• Deliver eligibility determination results to applicant • Provide online shop/compare/plan selection functionality for Exchange     enrollees

• Store new Exchange subsidies and employee coverage cases centrally for 

ongoing case maintenance• Send new MAGI and non‐MAGI Medi‐Cal cases to appropriate County SAWS 

system for ongoing case maintenance• Send new CHIP cases to MRMIB for ongoing case maintenance• Update master health care coverage client index• Retrieve information to support service calls

Governance

CHHS

DHCS

CDSS

Exchange 

Board

MRMIB

Service 

Center

Respond to 

consumer 

calls

Process mail

Service 

Center

Respond to 

consumer 

calls

Process mail

Counties/SAWS systems•Determine eligibility for MAGI 

Medi‐Cal and non‐MAGI Medi‐Cal & 

return results to CITI

•Store new MAGI and non‐MAGI 

Medi‐Cal cases and perform 

ongoing case maintenance

Counties/SAWS systems•Determine eligibility for MAGI 

Medi‐Cal and non‐MAGI Medi‐Cal & 

return results to CITI•Store new MAGI and non‐MAGI 

Medi‐Cal cases and perform 

ongoing case maintenance

MRMIB/MAXIMUS system•Determine eligibility for CHIP & 

return results to CITI

•Provide online shop/compare/plan 

selection functionality

•Store new CHIP cases and perform 

ongoing case maintenance

MRMIB/MAXIMUS system•Determine eligibility for CHIP & 

return results to CITI•Provide online shop/compare/plan 

selection functionality•Store new CHIP cases and perform 

ongoing case maintenance

Consumer ViewConsumer View

Option #1: Distributive

DHCS Contractor 

Provide online 

shop/compare/

plan selection 

functionality

DHCS Contractor 

Provide online 

shop/compare/

plan selection 

functionality

Central IT Infrastructure (CITI)• Provide website offering ACA required  functions• Determine eligibility for Exchange subsidies, employee coverage

and MAGI 

Medi‐Cal• Obtain eligibility determination for non‐MAGI Medi‐Cal from appropriate 

County SAWS system• Obtain eligibility determination for CHIP from MRMIB system• Deliver eligibility determination results to applicant •Provide online shop/compare/plan selection functionality for Exchange and 

MAGI Medi‐Cal enrollees• Store new Exchange subsidies, employee coverage and MAGI Medi‐Cal cases 

centrally for ongoing case maintenance• Send new non‐MAGI Medi‐Cal cases to appropriate County SAWS system for 

ongoing case maintenance• Send new CHIP cases to MRMIB for ongoing case maintenance• Update master health care coverage client index• Retrieve information to support service calls

Governance

CHHS

DHCS

CDSS

Exchange 

Board

MRMIB

Service 

Center

Respond to 

consumer 

calls

Process mail

Service 

Center

Respond to 

consumer 

calls

Process mail

Counties/SAWS systems•Determine eligibility for non‐MAGI 

Medi‐Cal & return results to CITI

•Store new non‐MAGI Medi‐Cal 

cases and perform ongoing case 

maintenance

Counties/SAWS systems•Determine eligibility for non‐MAGI 

Medi‐Cal & return results to CITI•Store new non‐MAGI Medi‐Cal 

cases and perform ongoing case 

maintenance

MRMIB/MAXIMUS system•Determine eligibility for CHIP & return 

results to CITI

•Provide online shop/compare/plan 

selection functionality

•Store new CHIP cases and perform 

ongoing case maintenance

MRMIB/MAXIMUS system•Determine eligibility for CHIP & return 

results to CITI•Provide online shop/compare/plan 

selection functionality•Store new CHIP cases and perform 

ongoing case maintenance

Consumer ViewConsumer View

Option #2: Partially Integrated

DHCS Contractor 

Provide online 

shop/compare/

plan selection 

functionality

DHCS Contractor 

Provide online 

shop/compare/

plan selection 

functionality

Central IT Infrastructure (CITI)

•Provide website offering ACA required functions• Determine eligibility for all types of health care coverage• Deliver eligibility determination results to applicant •Provide online shop/compare/plan selection functionality for all

applicable types• Store all health care coverage cases centrally for ongoing case

maintenance• Update master client index for all health and human services programs• Retrieve information to support service calls

Governance

CHHS

DHCS

CDSS

Exchange 

Board

MRMIB

Service 

Center

Respond to 

consumer 

calls

Process mail

Service 

Center

Respond to 

consumer 

calls

Process mail

Counties/SAWS systems

Determine eligibility and 

enrollment and on‐going case 

maintenance for human 

services programs: CalFresh, 

TANF, etc.

Counties/SAWS systems

Determine eligibility and 

enrollment and on‐going case 

maintenance for human 

services programs: CalFresh, 

TANF, etc.

MRMIB/MAXIMUS system

(System retired)

Consumer ViewConsumer View

Option #3: Fully Integrated

DHCS Contractor 

(System retired)

Q & A

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Questions for the Break-out Session

Are the decision criteria appropriate for evaluating the options? Why or why not? What would you change?Are the principles adequately reflected in the options? Are the principles appropriate? What would you change?What are the pros and cons of each option?Are there other options that should be considered?

Group Summary Feedback

Public Q & A

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Next Steps

• Board presentation on design options on September 27, 2011• Board decision on overall design vision on October 21, 2011• Solicitation draft target date, November 2011, for public comment • Board approves Solicitation on December 20, 2011

Send all stakeholder comments to: eestakeholdercomments@hbex.ca.gov

by Monday September 19, 2011

Thank You