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Appendices
Appendix Table 1: Decision Matrix
The determinations below take into account stakeholder interviews, background research, and analysis of the political and policy landscape both in Maine and nationally.
To generate rankings, we assigned numeric scores to each color determination, weighting consumer impact more heavily. This framework was selected because the core of a promising policy is not the ease of implementation but rather its impact on consumers with respect to affordability, complexity, coverage, and equity. For instance, if a policy is feasible but has limited positive impact on consumers, we consider it to hold less value than a policy with a stronger positive consumer impact that may face higher feasibility concerns.
TERMINOLOGY
Consumer Impact
• Potential Impact on Affordability - What is this recommendation’s impact on premiums, deductibles, and other cost-sharing for consumers? • Potential Impact on Complexity - How does this recommendation impact the ease by which consumers can navigate accessing health coverage? • Potential Impact on Coverage - How does this recommendation impact uninsured levels, while also considering different impacts across different populations? If applicable, how does it affect whether people are getting the coverage they want? • Potential Impact on Health Equity - How does this recommendation impact health care access for historically marginalized populations in Maine?
Feasibility
• Political Feasibility - How likely will this recommendation move through the administrative or legislative process? How will stakeholders play into helping advance or stymie a particular proposal? How does the federal government’s involvement play into this recommendation? • Financial Feasibility - What is this recommendation’s cost to the State in terms of budget impact? • Implementation Capacity - What is the capacity of Maine state agencies to implement this recommendation including both the initial implementation and ongoing implementation?
SCORING AND COLOR KEY
KEY
Dark green shade indicates significant/broad positive consumer impact or strong feasibility.
Light green shade indicates positive yet limited consumer impact or likely straightforward feasibility.
Grey shade indicates neutral consumer impact.
Light red shade indicates negative yet limited consumer impact or limited feasibility.
Dark red shade indicates significant/broad negative consumer impact or lack of feasibility. SCORING
CONSUMER IMPACT
FEASIBILITY Dark red = -3 Light red = -1 Light green = 1 Dark green = 3
APPENDIX 1 | 67
State Feasibility
Consumer Impact
Score Implementation
Capacity
Financial Feasibility 19 19 17 15 21 13 11 9 7 15 15 13 13
Political Feasibility*
Potential Impact on Health Equity
Potential Impact on Coverage
Potential Impact on Complexity
Potential Impact on Affordability
Policy Broader Recommendations
Invest in consumer assistance. Integrate consumer engagement into the process of designing and implementing Maine’s state-based marketplace. As a longer-term initiative, re-establish the Maine Office of Health Equity and empower its staff to coordinate equity efforts across the SBM, MaineCare, and all DHHS Offices.
Enrollment Periods
OEP - Earlier Start Date OEP - Later End Date SEP - Public Health Crisis SEP - Pregnancy SEP - Eligibility/Technical Issues During Open Enrollment SEP - Tax Filing
Displaying Clear Choice Plans
Use an intake questionnaire and show plans based on responses Build a comparison tool that: (1) auto matically highlights differences between selected plans, and (2) includes a “Com pare to Similar Plans” function Include a pop-up glossary feature when customers hover over a technical term, and enable screen reading audio capa bility for accessibility Distinguish Clear Choice plans with naming, visual cues, sorting, and/or filtering
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State Feasibility
Score Implementation
Capacity
Financial Feasibility
Political Feasibility* 19 17 15 13 3 21 13 9 13
Consumer Impact Potential Impact on Health Equity
Potential Impact on Coverage
Potential Impact on Complexity
Potential Impact on Affordability
Policy Auto-Renewal
Design more consumer-friendly auto-re newal notices for consumers. Set the default for consumers eligible for cost-sharing reductions to high-value silver plans. Auto-renew consumers with discontin ued plans into Clear Choice plans. Explore using auto-renewal defaults to incentivize carriers to lower costs. Consider allowing consumers to choose their auto-renewal priorities
MaineCare Integration
Conduct a joint strategic planning effort across the Department of Health and Human Services Resolve consumer-facing bottlenecks in MaineCare and SBM enrollment, specif ically: 1) dedicate greater resources to solicit input from enrollment assisters, 2)improve the notification process for enrollment, 3) ensure that new portals make it easy to access and view enroll ment status, and 4) explore the possibil ity of a “one-stop shop” for applications to both programs. Work with other Maine agencies to implement and evaluate innovative approaches to increase MaineCare
and marketplace coverage by directing
outreach towards Mainers identified through income tax filing or UI claiming who lack coverage.
Planning for the Future
In the procurement, implementation, and maintenance of the SBM eligibility and enrollment system, prioritize platform capacity to adjust the inputs for the rules engine to adapt to future policy innova tion.
APPENDIX 1 | 69
Appendix Table 2: Uninsured Rates, By Demographic Groupi
Demographic Number of Residentsii Uninsured Rateiii
Male 646,177 9.1% Female 681,446 7.0% 19-25 104,980 13.4% 26-34 145,795 14.1% 35-44 152,048 11.7% 45-54 175,132 12.1% 55-64 210,347 8.5%
White alone, not Hispanic or Latino 1,248,381 7.8%
Hispanic or Latino (of any race) 22,416 9.3%
Black or African American alone 21,465 8.4% American Indian and Alaska Native alone 9,317 18.2% Asian alone 15,203 9.7% Two or more races 27,653 12.5% Some other race alone 5,382 8.2% <100% FPL 141,734 12.9% <138% FPL 219,680 13.3% 138% to 399% FPL 568,033 9.8% ≥ 400% FPL 514,161 4.1%
i Maine ACS 2019 Estimates; some demographics not represented ii Insured and uninsured, estimated iii Estimated
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Appendix Table 3:
Recommendations For Technology Improvements and Integration Between SBM And OFI
Recommendations
1. Make exchanging information between the SBM and OFI as
seamless as possible. Platforms should be able to seamlessly exchange applicants’ details, including documents they have uploaded and determinations made by eligibility systems.
2. Offer applicants the capability to upload documents for eligi-
bility verification. My Maine Connection does not currently offer this functionality. This creates significant hassle for applicants and lost productivity for OFI staff, as applicants must mail, e-mail, fax, or deliver documents in person that verify their eligibility. As a DHHS working group noted, “lost documents and lengthy back and forth communications between Department staff and clients cause significant delays in the processing of benefits.”174
As a result of these frictions, MaineCare applicants that are determined ineligible may face longer delays in enrolling on the marketplace and may need to rely on an SEP to enroll. This can result in coverage gaps.
The lack of an upload service also increases demand elsewhere for OFI: because MaineCare applicants cannot accomplish everything online, many apply in-person or over the phone, which leads to long waits for assistance. The SBM RFP called for document upload tools.
OFI intends to make progress on this issue. Deloitte was contracted to redesign My Maine Connection’s front-end, and as part of this work, some back-end features like document uploading are expected to be featured.175
3. Automatically import high-quality data into ACES, removing
the need for manual entry. The Federal Data Services Hub is available to the FFM and SBMs. It enables the systems to pull relevant data held by various federal agencies which could impact eligibility for Medicaid and APTCs.
APIs could pull information from the data hub and format it in a way that is compatible with the Automated Client Eligibility System (ACES). Afterwards, algorithms or business rules can automatically populate and update the data and information on ACES, using data held in staging tables. This would significantly reduce the administrative burden on OFI to perform side-byside comparisons. DHHS requested that the SBM platform interface directly with the Federal Data Services Hub as part of their SBM RFP.
Moreover, a DHHS working group anticipates that Deloitte’s My Maine Connection redesign will lay important groundwork for automating data entry into ACES.176
4. Use the same Medicaid eligibility rules for the SBM and OFI
systems. Different rules engines can produce different assessments, which increases administrative burden on OFI and is confusing for applicants to navigate. Importantly, the marketplace should maintain separate business rules for the determination of APTCs.
5. When possible, make platforms and systems mobile-friendly.
Multiple stakeholders, especially assisters and navigators, emphasized that the State must consider Internet access when developing its application systems. Many of Maine’s rural communities still lack reliable broadband access, and interviewees recounted multiple experiences working with consumers whose only home Internet connection was on their mobile phones.
Planned State Actions
As part of their SBM RFP, DHHS requested a technology platform that enables the transfer of images, documents, and eligibility verification information between OFI and the SBM.
OFI noted the importance of account transfer files created by the SBM vendor being in a standard format (for processing in the ACES rules engine). Alternatively, a translation layer created by the SBM vendor could ensure the data from account transfer files can be processed in the ACES rules engine. The SBM is moving in this direction. In the SBM RFP, DHHS stated the goal to “[u]se API to leverage State’s Automated Client Eligibility System (ACES) business rules whenever possible while maintaining a separate SBM rules engine and business rules for SBM-only determinations (e.g., APTC)”. The SBM RFP identified “usability and adaptability for mobile devices” as a core function. It is unclear but likely that this includes mobile document upload functionality.
The Integrated Online Services RFP, currently being delivered by Deloitte, called for the system to perform “equally” on mobile and desktop hardware, and asked for the vendor to integrate “document and photo uploads” with DHHS systems.177 APPENDIX 3 | 71
