22 minute read
MaineCare Integration
Transitioning to an SBM could provide the State the opportunity to better integrate the marketplace with MaineCare. Our conversations with state officials uncovered a number of existing technology challenges that stand in the way of seamless FFM and MaineCare integration. Other conversations with external stakeholders identified multiple adverse impacts that applicants experience under the current system and uncovered best practices that SBMs have operationalized to improve their application and determination processes.
This section outlines our key findings and recommendations for delivering an SBM that is well-integrated with MaineCare and well-placed to help the State deliver on its goals of increased insurance enrollment. Our recommendations for Maine officials working on the SBM transition are the following: 1. Use existing state data to target and personalize outreach to facilitate enrollment.
2. Resolve consumer-facing bottlenecks in Maine-
Care and SBM enrollment.
3. Conduct a joint strategic planning effort across
DHHS.
Background
One of the key principles of marketplace design outlined by the ACA is the principle of “no wrong door.”148 A resident should be able to log on to HealthCare. gov or their state’s marketplace and be enrolled in Medicaid if they meet their state’s Medicaid income and eligibility requirements. In addition, a resident that applies for and is denied Medicaid coverage should be referred to the marketplace for coverage. Maine is an assessment state, meaning that the FFM makes an initial assessment of whether applicants are eligible for Medicaid, and then refers these applications to OFI for a final determination. Assessment states on the FFM can have difficulty making timely use of data associated with Medicaid referrals coming from the marketplace, which can result in a disjointed application process for consumers. Conversely, when states refer individuals denied Medicaid to the FFM, it is difficult for states to determine whether those consumers acquired coverage. States that operate SBMs typically have better integration with their Medicaid offices, and are better equipped to deliver upon the objectives of “no wrong door.” Managing populations that experience changes in coverage, otherwise known as “churn,” is another key challenge that requires close integration between the marketplace and Medicaid. Poor integration between systems can increase the administrative burden experienced by state agencies and marketplace staff that oversee churn and lead to delays or barriers for Mainers seeking coverage. A 2016 study found that one in four individuals with household incomes below 138% FPL experienced a coverage change—this figure was consistent between participating expansion and non-expansion states.149 Adverse impacts of churn from Medicaid to the marketplace are well-documented, and these impacts can be exacerbated if the State cannot assist individuals through coverage changes in a timely manner.150 Figure 7 describes the ideal setup for SBM and MaineCare integration from the consumer perspective. In this setup, consumers are able to easily navigate and access the insurance plan most appropriate to their eligibility status.
Ideal Setup
for SBM and MaineCare integration for consumers
Consumer seeks health insurance
If needed, obtains assistance
(e.g., from an assistor, navigator, or community-based organization that works closely with DHHS and has access to enrollment status details online)
Consumer applies for insurance somewhere
State determines eligibility:
NO WRONG DOOR
State seamlessly redirects consumers to the appropriate health plan based on their application details.
Consumers (and their assisters) are notified promptly and clearly regarding status updates
Consumer is enrolled and insured under the appropriate plan
(e.g., MaineCare or the SBM with subsidies)
Existing roadblocks prevent Maine from achieving this ideal SBM/MaineCare setup:
• Enrollment assisters currently cannot easily view the application or enrollment status of an individual they are helping.
• There is an opportunity for DHHS to work more closely with enrollment assisters to identify enrollment bottlenecks and foster longer-term collaboration.
• Currently, consumers have to determine whether to apply for MaineCare or enroll through the marketplace. Sometimes, consumers applying through the ‘wrong’ door have to repeat the process again for the
‘correct’ door, after waiting to learn whether they have been denied by the first door. This is currently the case for individuals deemed ineligible for MaineCare by OFI, who then need to initiate their own application for the marketplace.
• Other states, including California and
Massachusetts, have a single application portal for both Medicaid and their SBM, allowing these states to more seamlessly move consumers to the appropriate program.
• In early 2018, approximately 3 in 4 MaineCare applicants waited longer than a month for their applications to be processed, after which they were notified of the result via mail.
Later, if the consumer’s eligibility changes (e.g., due to a change in income), they are notified, assisted, and enrolled in a more appropriate plan
Efficient processes for handling churn
Repeat process as needed
• There are concerns about whether FFM enrollees are being notified promptly that they could be eligible for MaineCare if they experience a drop in income.
• The potential transition to an SBM is an opportunity to streamline churning processes and ensure Mainers are enrolled in the best coverage for their needs, including leveraging data to predict candidates likely to experience churn.
Box 1: MaineCare application processing times
When Medicaid and marketplace systems are not well-integrated, consumers seeking coverage can experience long delays and breaks in their enrollment journey. There is currently room for improved integration between OFI and the marketplace, and an SBM could add significant value for residents and state agencies. This box presents aggregate administrative data on Medicaid application processing times to highlight opportunities for improved integration and efficiency.
Slow processing of FFM referrals
At our request, OFI provided us with data on Medicaid application volumes and processing times broken down by source for 2018.i Table 4 presents this data and demonstrates that referrals from the marketplace face by far the slowest processing times of any application type. OFI stressed that FFM referral processing times reflect the influx of applications the office receives during the OEP. In other words, FFM applications take the longest to process on an annualized basis because, unlike other types of applications, they arrive in large volumes during a brief period of time. While OFI noted that it has been better resourced to handle application influxes in more recent OEPs, the data strongly suggest that there is significant potential for improving integration between
the marketplace and OFI’s operations.
Table 4. MaineCare application processing volumes and times, by source (2018)
Source Applications Received Days to Process Number Pct. of Total < 1 day 1-7 days 8-30 days 31-45 days 45+ days FFM 10,396 14% 0% 0% 5% 14% 80%
In-person 26,342 36% 13% 31% 24% 13% 19%
Online 17,220 24% 3% 9% 27% 23% 39%
Paper 19,280 26% 0% 12% 25% 24% 39% TOTAL 73,238 100% 5% 16% 22% 18% 38%
Source: OFI
Delayed processing times can have significant consequences for those on the cusp of MaineCare eligibility. Four in five referrals from the FFM face wait times for applications that exceed the length of the 45-day OEP window. Applicants that are denied coverage through MaineCare and referred back to the marketplace can only enroll there under an SEP and after confirming their eligibility, adding extra steps to the process of securing health insurance.ii
Slow Medicaid application processing compared to national averages
Data on Medicaid application processing times from February through April 2018, presented in Table 5, show that Maine was the slowest of 42 states reporting data.151 As discussed above, slow processing times can adversely affect Mainers who apply for and are denied Medicaid during (or just before) the OEP: individuals must navigate the additional hurdle of proving their SEP eligibility and endure longer delays associated with enrolling.152 Table 5. Medicaid application processing times, Feb-April 2018 (“National” includes ME)
Month < 24 hrs 1-7 days 8-30 days 31-45 days 45+ days
Maine National Feb 5.7% 3.0% 8.9% 5.1% 77.2% 30.8% 15.1% 27.2% 8.7% 18.2%
Maine
National March 6.7% 3.4% 10.5% 53.6% 25.8%
30.0% 15.8% 25.2% 9.3% 19.7%
Maine National April 7.4% 3.7% 9.9% 55.5% 23.6% 32.0% 16.8% 25.6% 7.8% 17.9%
Source: “Medicaid MAGI and CHIP Application Processing Time Report.” CMS, November 28, 2018. Accessed December 17, 2020. https://www.medicaid.gov/state-overviews/ downloads/magi-and-chip-application-processing-time/magi-application-time-report.pdf.
i We requested 2018 data because 2019 and 2020 are what we consider “outlier” years: Maine expanded Medicaid in January 2019 and was overwhelmed by applications in the early part of the year, and the coronavirus pandemic has changed the eligibility and determination process for states in 2020. Although 2018 is not the most upto-date reflection of OFI’s operations, processes, and policies—which OFI stressed—we believe it is the most recent calendar year snapshot that offers a glimpse into “business as usual” operations. Other data extracts which cover shorter time horizons (perhaps from mid- or late-2019 through early 2020) may be preferable. ii We understand that the State has extremely limited visibility into what happens to referrals it makes to the FFM. It is therefore difficult to provide a comprehensive assessment of the integration between the two systems for these referrals.
Interviews with stakeholders both directly and peripherally involved in the SBM transition provided the foundation for our recommendations. This section provides a high-level synopsis of key themes that surfaced across stakeholders.
There are clear opportunities for improvement in technological integration between the marketplace and OFI’s systems
OFI leadership identified issues that constrain their ability to process marketplace referrals: • Data quality: The quality of data that OFI receives from the FFM is, in their view, not very high. To compound this problem, it is not easy to get answers from the marketplace on what the data received represents. Specifically, CMS has not identified certain data fields in files it sends OFI which they need to enroll and manage MaineCare members. • Data formats and systems: Another problem identified by OFI relates to the specific data file formats and structures that OFI receives. The files shared by the FFM do not integrate well with OFI’s
Automated Client Eligibility System (ACES), which
OFI uses to determine eligibility for MaineCare and other social service programs and which does not yet have the capability to automatically import and process data from an outside source. • Manual entry: In order to process these marketplace referrals, OFI staff must in every instance perform a “side-by-side” comparison of information they receive from the marketplace and information which they already have on file in their ACES. Differences and data fields are reconciled with manual entry by OFI staff. • Different eligibility rules: The eligibility systems and rules are not the same between the FFM and
OFI, and there are certain pathways (i.e. bugs or loops) where an FFM eligibility check makes a referral to OFI, only for OFI to reject the application and refer it back to the FFM. Appendix Table 3 highlights best practices for integrating OFI’s operations with SBM systems and assesses the extent to which Maine plans on implementing these practices and other technological improvements. By implementing the practices outlined in the table, Maine could provide its residents with a superior enrollment experience and move towards its stated goal of making more automated, “real-time” Medicaid determinations via the SBM for a significant proportion of applicants.iii This represents a clear example of how Maine could maximize its SBM work to benefit OFI and MaineCare applicants and members.
One-way and/or bottlenecked communication channels are making it more difficult for the State to reach and better understand Mainers
As illustrated by Figure 7, consumers in Maine still face a number of challenges navigating and accessing the health plans most appropriate for them. Enrollment assisters, which we define to include navigators, assisters, certified application counselors, and community organizations, play a crucial role in supporting these consumers. We have identified a number of opportunities in which the State can partner more closely with these consumer-facing stakeholders to more effectively reach community members.
Competing priorities and unclear decision-making processes create inefficiencies within DHHS OFI’s duties extend beyond MaineCare and include the screening and administration of four
other means-tested programs: Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Higher Opportunity for Pathways to Employment (HOPE). Although this structure and issue is common in other states, interviewees believe this creates competing priorities for staff, especially for those tasked with ensuring compliance with SNAP’s federal deadlines. This could potentially be one factor in MaineCare’s relatively slower processing time, likely resulting in suboptimal experiences in churn and longer waits for people to receive their eligibility assessment. Compared to previous administrations, there is currently a much deeper focus on customer service and processing times are expected to decrease.
In the context of leading Maine’s potential transition to an SBM, DHHS has key opportunities to better coordinate between OFI and OMS. Both OFI and OMS have been included in planning since initial conversations about the potential transition but advocated for a greater role in future planning. This is more so the case for OMS, which is not directly connected to the FFM and relies on OFI as its liaison. The potential transi-
tion to an SBM is an opportunity for DHHS to capitalize on the insights of OFI and OMS and improve the overall health insurance system.
Lastly, when new initiatives are developed be-
tween OMS and OFI, the process to determine where additional staff or resources to support
those changes come from is unclear. Without establishing clear delineations of resources or a decision-making model for joint efforts, this matter could become even more confusing following a transition to an SBM.
An SBM technology platform integrated with OFI systems could enable DHHS to present personalized and accurate information about the subsidies Mainers would be eligible for or types of coverage they could receive at no or low cost. This integration could be leveraged when MaineCare members churn off the program.
Beyond churn, Maine officials can take advantage of increased access to individual-level data on marketplace health insurance coverage.iv By combining this marketplace data with existing DHHS data on MaineCare enrollees—and potentially data from other state agencies—DHHS can generate a more comprehensive picture of who is covered in the state and whether certain enrollment gaps exist for specific groups of Mainers, even in the absence of a state mandate.
DHHS could partner with other state agencies, such as the Bureau of Unemployment Compensation and Maine Revenue Services, and arrange for the sharing of individual-level data in order to identify Mainers who are likely eligible for MaineCare or subsidized marketplace coverage, given their reported AGI or change in employment status. Maine officials could then conduct targeted outreach, inviting these individuals to apply for coverage. There is recent precedent for this work in SBM states: Maryland’s “Easy Enrollment” program, launched this year and outlined in the Enrollment Periods section, asks uninsured state tax filers for their consent to share their information with the State’s marketplace “for the purpose of determining pre-eligibility for nocost or low-cost health care coverage.”153 As of July 2020, of the approximately 41,000 tax filers that consented to data sharing, approximately 9% (3,700) enrolled in either marketplace or Medicaid coverage.154
Consumer Impact
The vast majority of Mainers who lack coverage are low-income and likely eligible for MaineCare or APTCs. Outreach could reduce complexity that uninsured Mainers face when applying for coverage by directing Mainers to the right “door.” More intensive outreach, such as outbound phone calls, could help Mainers better understand how they stand to benefit and what they need to enroll. Ultimately, outreach efforts could lead to many more Mainers enrolled in MaineCare or marketplace coverage with subsidies. For instance, if only half of uninsured Mainers with household incomes less than 400% FPL were identified by Maine Revenue Services for outreach, that could produce a list of about 42,000 Mainers who could be contacted. Even modest takeup rates in response to outreach within this group could lead to thousands of additional Mainers insured. Moreover, those who are most likely to change their behavior in response to outreach are typically those that stand to benefit most.
State Feasibility
Conducting this outreach presents a number of obstacles DHHS should consider. Besides getting buy-in from key State stakeholders, legislation would likely be needed to change tax forms and/or enable the sharing of individual-level income tax return data between Maine Revenue Services and the SBM.v This was the case for Maryland’s Easy Enrollment program; legislation creating and supporting the program passed with significant bipartisan support.155
Fully automating the targeting process with high accuracy would likely be difficult, but agencies could likely identify many potentially eligible individuals using personal identifiers common across data sets. Finally, there are naturally costs to outreach activities, and more personalized forms of outreach (e.g., phone calls) are more expensive—but modest forms of outreach should pose fairly limited costs per enrollee added. Recommendation 2: Resolve consumer-facing bottlenecks in MaineCare and SBM enrollment.
There are a number of opportunities to improve upon the State’s consumer-facing processes. In the nearterm, DHHS should partner more closely with enroll-
iv The State may be able to capitalize on this data under the SBM-FP. v We are not in a position to say confidently whether legislation would be needed. Appendix D of the Report to the Legislature pursuant to Public Law 2019, Ch. 485, February 2020 suggests that only “agreement” is needed between DHHS and Maine Revenue Services for various activities leveraging income tax filings. MAINECARE INTEGRATION | 49
ment assisters to make it easier to notify and support enrollees who are navigating their way into or across MaineCare and the SBM. In the long-run, DHHS should explore whether to join other states that have set up a “one-stop” application system for both Medicaid and marketplace subsidies.
Dedicate greater resources to solicit feedback from enrollment assisters to identify enrollment process issues.
For instance, officials at OFI noted a data gap relating to a group of consumers they are working to better understand. Specifically, they have little information on the potential enrollees who either never start an application or who open one but never finish it. In our interviews, navigators and community organizations shared insights on this phenomenon that we believe would be useful to DHHS. Several questions and issues were raised in our interviews that we believe merit further study: • Which qualifying individuals are not completing or willing to enter the current application processes for insurance/benefits, and why? (Possible factors suggested in our interviews include technological and internet access challenges, particularly access beyond mobile devices; language barriers; and the complexity of the enrollment process.) • What best practices have navigators/groups employed to improve completion rates and conduct effective outreach? What steps can be simplified or streamlined, including in a potential SBM? • How much is Medicaid Estate Recovery preventing near-retirement aged individuals from participating? (Multiple stakeholders raised this issue.) As described in the Health Equity Approach and Broader Considerations sections of this report, it is important that efforts to engage community organizations and enrollment assisters not be duplicative, which would be inefficient for state resources and community advocates. For instance, consider if OFI were to hold a meeting or conduct a survey on MaineCare enrollment issues. If SBM staff simply repeat these efforts on marketplace enrollment issues, much of the content may be the same, and an opportunity to understand key overlaps and differences would be missed. Depending on the situation, potential solutions include co-hosting meetings, sharing notes between groups, and ensuring that relevant stakeholders are present at both meetings (e.g., a Director of Health Equity or other health equity coordination staff).
Improve the notification process for enrollment, especially among churning populations.
According to both state officials and consumer advocates, DHHS can improve how it delivers important notices regarding insurance status, especially among those transitioning between MaineCare and marketplace plans. During Medicaid expansion, OFI noticed a slow uptake rate among new enrollees even after launching a targeted campaign to notify individuals that they could now qualify for MaineCare. OFI staff expressed a keen interest in tackling these issues and have already begun exploring solutions. We further recommend that the State:
• Create a process where enrollment assisters are also notified when an individual they previously assisted needs to take action relating
to their insurance status. During enrollment, make this the default selection but allow consumers to opt-out of this feature. For instance, should the
State need to notify an individual that they no longer qualify for MaineCare and should enroll in a marketplace plan with subsidies, their prior assister can be alerted and follow up with the individual to support them. This system would be particularly helpful for consumers who face greater barriers to enrollment (e.g., due to language, internet access, and/or their community’s historical relationship with the government) and decrease the number who fall through the cracks as they move out of either program.
• Re-design notices to make them more ac-
cessible and easier to understand. According to OFI, the current notification system for those deemed ineligible for MaineCare involves two letters: first, a denial letter from OFI, and second, a letter with opportunities from the marketplace. Moving forward, notifications for both “no wrong door” and churning populations should be streamlined to be more accessible to consumers.vi
Employ user-friendly design principles to make it clear to consumers what is happening with their insurance, what action they need to take, and who they can contact for assistance. Prominently list the direct contact information of enrollment assisters, especially any with whom the consumer previously worked (based on feature above).
List coverage options clearly and up front. Employ
vi According to DHHS officials, OFI recently implemented newly designed notices, for the first time in the two decades since the State began using its Automated Client Eligibility System. 50 | MAINECARE INTEGRATION
social norms and positive language to eliminate stigma associated with enrolling in either plan.156 (E.g.,
“Like 8 in 10 Mainers, you qualify for subsidies that allow you to enroll in a more affordable health insurance plan. Take five minutes today to update your information through our state health portal.”)
• Diversify the mode of communication, particularly among “no response” individuals.
Especially among individuals who do not respond to mailed notices promptly, we recommend also employing email or text message notifications and using proactive phone calls to contact them about action required. This is likely to improve response rates, especially if consumers are able to respond to any of these channels to get in contact with enrollment assistance.
Ensure that an SBM consumer portal and its OFI/MaineCare equivalent are easy for consumers and assisters to access, view, and understand their enrollment status.
According to the State’s RFP, the new SBM consumer portal is expected to have backend data integration with OFI’s systems, which would offer consumers and their enrollment assisters greater visibility into their enrollment status. As OFI designs and builds the replacement for My Maine Connection, it is critical that its own consumer portal also offer the same functionality. Navigators and community groups emphasized the importance of this feature, noting that it could help them more easily monitor and support consumers, especially those with greater access challenges to begin with (e.g., limited internet access or language barriers).
Over the medium to long term, DHHS should explore the pros and cons of Maine adopting a “one-stop shop” where Mainers can apply for MaineCare, APTCs/marketplace plans, and other benefits in a single, unified application.
Other states, including Massachusetts and California, have integrated application and eligibility systems, which allows for easier mixed eligibility enrollment and plan management (e.g., in Massachusetts the state system manages families where parents are on the SBM plan but children are on Medicaid/CHIP at the same time).157 In addition to reducing confusion, complexity, and choice proliferation for consumers, a single eligibility portal can also help to eliminate the stigma or hesitation consumers may have regarding Medicaid that might otherwise prevent them from applying. On the backend, a single system also means that OFI, OMS, the SBM, and other agencies administering benefits could access and update data in a uniform manner, which would improve coordination between offices. It would also allow for longer-term relationship management between state agencies and Maine residents, especially those in communities that may harbor distrust or skepticism towards government due to negative historical or past experiences.
Consumer Impact
These sub-recommendations will improve “no wrong door” and support churning populations, making it easier for consumers to get enrolled and obtain information from either DHHS or enrollment assisters about which plan is more appropriate for them. Moreover,
working more closely with enrollment assisters and community-based organizations to address enrollment issues will particularly help Mainers with higher barriers to health access, including those with historically marginalized identities.
Feasibility
All of these recommendations require buy-in from multiple departments and external organizations, but it appears that stakeholders are on board provided they are given adequate support from DHHS to prioritize these issues among other projects. The bulk of financial costs for these proposals are associated with web portal development and data integration, especially if the State eventually decides to pursue a “one-stop” platform. Recommendation 3: Conduct a joint strategic planning effort across DHHS.
Given the transformative nature of the potential SBM transition, administrative challenges of serving the churn population, time-sensitivity of providing health insurance coverage, and the number of stakeholders involved, we recommend DHHS lead a strategic planning process. At minimum, this should include MaineCare, OFI, incoming SBM staff, and DHHS leadership. Table 6 summarizes useful topics for a strategic planning process and their anticipated benefits. Facilitating this “big picture” visioning exercise for the SBM transition will provide individual offices with an understanding of how their work fits into the larger mission and goals, increase staff buy-in for new policies, and help cross-pollinate best practices across DHHS. Along with uncovering insights, a strategic plan could include a work plan and action items that help facilitate better integration between OFI and the SBM. It is critical to dedicate staff to manage the implementation of and communication surrounding this process, and to aggregate and act on the lessons learned. This will allow the plan to remain iterative and adapt to Maine’s shifting health insurance needs.
Consumer Impact
Increased collaboration between Offices holds the potential to create a better consumer experience, especially facilitating a more optimal “no wrong door” experience and a more seamless churning process. Streamlining OMS and OFI’s role in the SBM transition will reduce coverage gaps, particularly for historically marginalized populations, by ameliorating administrative complexity.
State Feasibility
The strategic planning process would require staff time, a precious resource especially during the SBM transition. Though this may present initial challenges to various Offices’ individual priorities, in the long run we do not anticipate it would significantly affect the Department’s capacity.
Table 6. How Strategic Planning Topics Would Benefit the SBM Transition
Planning Topics
Strengths, Weaknesses, Opportunities, and Threats (SWOT) Analysis
Benefits for the SBM Transition
• Take stock of individual Offices’ assets and shortcomings • Coordinate collectively to create a shared vision and markers of success
Federal forecasting
Data inventory • Create contingency plans for upcoming Supreme Court decision and anticipate opportunities under Biden Administration • Compare existing data across Offices, identify opportunities to standardize and exchange • Pinpoint opportunities to create systems that capture desired data in the transition
Decision-making models • Establish transparent procedures for how decisions are made and how work and resources are distributed in joint DHHS efforts Accountability and Evaluation • • Ensure action items from strategic plan are followed through Create methodology to evaluate effectiveness of new systems
