‘No wrong door’ for health reform coverage? Not quite, official says

In theory, there will be “no wrong door” for Connecticut residents without health insurance to get signed up for coverage as part of the federal health reform law. They’ll be able to apply through the state’s new insurance marketplace and get connected through a computerized system to either a set of options for private insurance plans to buy, or free Medicaid coverage.

In reality, it might not be quite so simple.

For one thing, the process won’t be entirely automated for the estimated 55,000 people who will become eligible for Medicaid as of Jan. 1. Instead, because of outdated technology at the state Department of Social Services, information will have to be manually entered by a state contractor into the department’s eligibility management system, at least for the first year.

And even for people buying private insurance, getting through the eligibility process is not likely to be a simple transaction.

“Our thinking is only roughly 3 percent of people will be able to get by without some kind of phone call or assistance,” said Kevin Counihan, CEO of Access Health CT, the state’s health insurance exchange, a marketplace for people to buy insurance as part of the federal health reform law.

Access Health will have a call center for people to apply or seek information, and Counihan said the expectation is that the average call will last about 55 minutes. 

Still, Connecticut’s exchange is taking steps that Counihan believes could make the process smoother than it will be in many other states. 

Signing up

Access Health CT will begin taking applications Oct. 1 for health plans that take effect Jan. 1. The exchange is expected to enroll between 80,000 and 100,000 people in insurance plans in the first year.

Another 55,000 people are expected to become eligible for Medicaid Jan. 1, when the income limit for the program rises. 

People will be able to sign up in multiple ways. There will be an online application through the Access Health website, a way to apply through the DSS website, stores where people can go to sign up in person, a call center, insurance brokers and groups throughout the state trained to help people apply.

All the application information will be routed to an Access Health eligibility system. Applications for Medicaid will go through the same system.

The system will be able to verify information about applicants through a federal “data hub,” although Counihan said his organization is trying to reduce the need for reliance on the federal government for information.

What happens from there depends on what type of coverage the applicant is eligible to receive.

The Medicaid route: Part automated, part manual data entry

People found to be eligible for Medicaid will get a notice saying so. Because the expanded Medicaid coverage takes effect Jan. 1, anyone who applies before then will get a notice that their coverage is effective beginning in the new year.

The notice will also explain that it can be used as a guarantee of payment, said Kristin Dowty, DSS’ medical administration manager and the department’s lead on the Access Health project.

It could take longer before the client gets a Medicaid card, because that’s part of a process that requires manual data entry.

DSS is replacing its outdated eligibility management system, but in the meantime, information from the Access Health system will have to be entered manually into the eligibility management system, known as EMS. That’s necessary for the department to send information on clients to the organization that administers Medicaid, for claims to be processed, and for Medicaid cards to be printed.

Social Services Commissioner Roderick L. Bremby said the manual process is for administrative functions. The department is in negotiations with Xerox to do the data entry.

“I think, to be honest, we would like for the fully automated and integrated system to be functional Oct. 1, but that’s just an impossibility,” Bremby said. “So we’ll get the functionality of EMS replaced and linked to the marketplace as soon as we possibly can.”

Anytime there’s manual data entry required, there’s the possibility for information to be entered inaccurately, Counihan noted.

“Is that a cause for concern? Sure,” he said. “Is it one that I think the house is on fire? No.”

The private insurance route: Trying to minimize need for federal data

For the majority of people expected to seek coverage through Access Health, there will be two options: Buying coverage through the exchange with federal subsidies to discount the cost of premiums, or buying coverage without any discounts. The distinction is based on income, and the process for determining eligibility will be fully automated, Counihan said.

But it, like the system for determining Medicaid eligibility, will rely on the federal data hub, which provides access to information from federal agencies and other sources needed to verify information on people’s applications. A report on federally run exchanges released last by the Government Accountability Office warned that “much remains to be accomplished within a relatively short amount of time,” including work on the data hub.

The federal government requires that the exchanges verify 14 different pieces of information that states can get from the data hub, including information on income, citizenship and residency.

But Counihan said Access Health is working to reduce the number of items it relies on the federal government to get. About half those items, including income, can be verified with state-level data, and Counihan said the goal is to further reduce the number of interactions with the federal system required to process an application.

“The more we can do on our own, the less risky this is going to be,” he said.

“It’s not to say that we don’t trust the federal hub, but we’re just trying to make sure that we can do as much within our state, within our own system, as possible, and be less dependent on the federal eligibility verification as possible,” he said.

An estimated 49,000 state residents will qualify to buy insurance through the exchange but won’t qualify for any federal financial assistance to do so. Another 176,000 are expected to be eligible to buy plans through the exchange with federal subsidies that will reduce their monthly premiums.

They’ll receive a confirmation when the process is complete, letting them know whether they’ve qualified for a discount for their private insurance plans or can buy insurance without a discount. Then they’ll be able to start shopping for a plan.

In the first year, Access Health will have a six-month open enrollment period, from Oct. 1 to April 1. Counihan said most people are expected to enroll in the first two weeks of December and the first two weeks of March.

Medicaid staffing, expertise

DSS has struggled to process Medicaid applications within federally required time frames, something that’s landed it in court. So how will the department handle thousands of newly eligible state residents?

“DSS can’t keep up as it is,” said Sheldon Toubman, an attorney with the New Haven Legal Assistance Association who is suing DSS over delays in processing Medicaid applications. “They don’t have enough staff to keep up with the processing, and it’s going to get substantially worse.”

But Dowty said the majority of eligibility determination will be automated. Even if the federal data hub can’t verify something, eligibility rules allow the department to give the applicant 90 days to provide information. In the meantime, the person would receive coverage.

But in some cases, information will need to be handled by a DSS worker, she said.

“We don’t see this process as burdening existing eligibility service workers,” Bremby said. “They will have more than enough time in the future ensuring that these new customers or program participants are renewed and we keep up with their addresses and that sort of thing. So they’re going to be more than busy, but in terms of this particular part of the process, we don’t anticipate this being a significant impact at all.”

Toubman also questioned whether the Access Health system will ensure that anyone who qualifies will be routed to a Medicaid program, rather than to the exchange for coverage, since the income limits for Medicaid vary based on whether a person has minor children or is pregnant. While Medicaid is free, exchange plans will require even people who receive discounts to pay premiums and other out-of-pocket costs.

In particular, Toubman worries that people who could qualify for a Medicaid “spend down” could be particularly vulnerable to being routed to the wrong kind of coverage. A person with disabilities whose income is too high for Medicaid could still qualify for the program if the additional money is all spent on unreimbursed medical expenses, something known as a “spend-down.”

“I’m real worried that when you apply through the other end, it won’t really be no wrong door,” Toubman said.

Counihan said the Access Health system will take into account whether a person has children or is pregnant in determining whether qualify for Medicaid. Dowty said the system will be able to identify many people who would qualify for a spend-down. For example, she said, a person who reports being on Medicare and disabled would be encouraged to go to DSS to see about participating in the program with the spend-down.