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CMS Fine-Tunes a 'Single, Streamlined Application' Crucial to Health Law Success

By Jane Norman, CQ HealthBeat Associate Editor

March 1, 2013 -- In just seven months, millions of Americans are expected to start filling out what's supposed to be an easy-to-understand application for health insurance coverage under the health care law.

Public comments on a prototype exchange application that the Centers for Medicare and Medicaid Services proposed were due last week. And there are plenty of suggestions for improvement.

Consumers completing the form online, on paper or over the phone will be asked questions about everything from the health insurance their employers offer to their citizenship status to their sources of income. The answers will determine whether they are eligible for the Medicaid health program for the poor, for a federal subsidy to help pay for insurance, or neither.

This application is only a first step. It does not include a menu of plans, nor does it allow consumers to sign up for coverage. That would be a next step after exchange officials process the application and let consumers know what programs and/or plans they qualify for.

Many of the uninsured may not be too familiar with the ins and outs of health insurance. And the ease with they can fill out the application for enrollment in these new marketplaces will be crucial to the Obama administration's push for wide enrollment and the success of the overhaul law's (PL 111-148, PL 111-152) goal to extend coverage to most Americans.

Times Will Vary

At first blush, the 21-page paper version is one bulky packet. At a national meeting of health insurance brokers and agents earlier this week, members of the crowd jeered when speaker Chiquita Brooks-LaSure of CMS referred to the development of a "single, streamlined application."

However, a closer look shows some of the size of the paper version is due to pages allocated for the details on the income and insurance status of up to six household members. Online, applicants would be able to quickly click through those options if they're not needed, in a "smart" process designed to pose questions to applicants based on their previous answers.

The size of it "might be a little scary when you pick it up," said Karen Davenport, director of health policy at the National Women's law Center. "But if you're a household of three, you're not doing all 21 pages."

Nonetheless, for many, the introduction of a new federal form to be used by millions of Americans for health coverage brings back memories of the rocky introduction of the Part D Medicare prescription drug benefit in 2006, when the Department of Health and Human Services was deluged with complaints by panicked and confused seniors and their families.

Judith Solomon, vice president for health policy at the Center for Budget and Policy Priorities, applauded the prototype as a "good first start" though she acknowledged it also might seem "somewhat daunting."

The reality, she said, "is that a lot of people are going to need help"—which they presumably will get through navigators, assistants, call-in centers and more.

In its formal comments, the center also recommended that the application should help people determine first if they are eligible for Medicaid or the Children's Health Insurance Program, so they don't have to answer the many detailed income questions relating to eligibility for advance tax credits.

Karen Pollitz, a senior fellow at the Kaiser Family Foundation and a former top CMS official, said the prototype is "actually quite good" and that there's only so much CMS can do because it has to meet so many of the law's requirements. "It's not super simple and that's not the fault of the application; that's just the rules under the ACA," said Pollitz.

There's some concern in particular among consumer advocates about possibly confusing questions about a family's current access to health insurance. Applicants are asked for the name of the "lowest cost self-only health plan" offered at their jobs, the cost of premiums for that plan and whether it meets the "minimum value standard."

America's Health Insurance Plans, which represents the insurance industry, said in its comment that one major problem with the application is that it does not allow consumers to also pick their preferred plan and enroll in coverage.

"While the new Exchanges are viewed as an opportunity to ease the process for consumers, unfortunately, the paper applications do not achieve this goal," AHIP said. Not knowing that the next step will be to sign up for coverage makes the process appear incomplete, insurers said.

"The applications must be amended to avoid confusion and provide clear explanations of the steps in the process the applicant should expect," said AHIP. "To fail to do so will confuse, disappoint and possibly discourage applicants from applying for coverage."

CMS is in the final stages of devising the application's prototype, and last week's deadline for comments fell just a month after the prototype's official release. Some observers predict the final version may emerge as soon as a month to 45 days, as the administration steams toward the scheduled open enrollment kick-off on Oct. 1. Consumer are expected to be able to continue to sign up through March 31, 2014.

In addition, states may opt to develop their own applications, which is allowed under the law with CMS approval.

Most to Sign Up Online

Federal officials anticipate that most people will apply for insurance online. CMS estimates that 4.3 million people will submit applications to the exchanges in 2014, of which 3.9 million are expected to use a computer. CMS expects nearly 2 million more applications in 2015 via all methods and 2.8 million in 2016.

Opinions differ on that expectation for online sign up. At a meeting at Kaiser in January, Nico Gomez, deputy chief executive of the Oklahoma Health Authority, said that nearly 80 percent of his state's Medicaid managed care population were signed up for the program via the Web.

But Tricia Brooks, research assistant professor at the Georgetown University Health Policy Institute, said studies they've done show there's a wide variation among states when it comes to online Medicaid enrollment, dipping as low as 10 percent in some. The government can adopt strategies to nudge people toward the Web but "you're not going to get everyone there," said Brooks.

Brooks also said that the application doesn't ask about people's pre-tax contributions to dependent care accounts, for example, that could affect the amount of their reported income and thus whether they qualify for assistance.

A CMS spokesman said the laws and regulations were reviewed as part of the development of the prototype, which already has been tested four times among groups of people who lack insurance. Tests have been undertaken in multiple cities across the nation via one on one interviews. People were watched and questioned as they completed the form, the spokesman said. Final tests were conducted in February, the spokesman said. According to CMS documents, the cost of data collection and development for the application is estimated at $834,000 between 2014 and 2016, with an additional annual $89,000 cost for the salary of one full-time employee.

CMS also estimates it will take the average individual half an hour to complete the online form for those who are applying for Medicaid or federal subsidies, compared to 45 minutes for the paper version. It will take less time for those who don't qualify for either program but still want to buy insurance through the exchange.

Enroll America, a nonprofit group that's working with partners to promote enrollment, said in its comments submitted to CMS that it's important to realize that no matter how much simplification takes place, the application will remain challenging. The organization's own research finds that people describe feeling confused, overwhelmed, worried and helpless about finding insurance—which makes it doubly important they have prominent reminders in the course of filling out the application where they can call or visit for help, said Enroll America.

That means the existence of help should be stressed at every "troublesome spot" in the application, said the group.

Brooks said she knows that officials are working hard to perfect the application but bumps in the road should be expected. "It'll be a work in progress," she said.

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