States that expand Medicaid and establish Health Insurance Exchanges – both part of the Affordable Care Act (ACA) – should start planning early, should take advantage of time-limited federal funding to improve enrollment systems, and should emphasize online enrollment methods, says a brief from the Robert Wood Johnson Foundation’s Maximizing Enrollment initiative.  The authors devote most of their energies to emerging technologies – web portals, online tools, web chats, and e-mail – and how they might make enrollment easier for both Medicaid and subsidized health insurance coverage under the ACA health reform law.

The brief is a guide for states exploring options to create “no wrong door” enrollment systems – which provides a central portal for a variety of public and subsidized coverage options – and it distills best practices from states who have tested those methods or from customer service in other industries.

Online Enrollment is More Effective, Less Expensive:

Online enrollment and support tools have the potential to be more effective and more cost-efficient than other forms of customer service. Some highlights from the brief:

  • The average response from a telephone call center costs $33 while online chat costs $10 per encounter, according to one source cited.
  • Utah estimates that it saves $12 per year for every beneficiary who opts for electronic delivery of notices.
  • A recent study of lower-income adults in Alabama, Maryland and Michigan suggests that almost three-quarters of people are interested in enrolling online.
  • The Enroll UX 2014 project, a public-private partnership between foundations, the federal government, and 11 participating states has designed a user-friendly online application user interface that is available at no cost to all states.

Though such progress is very promising, the authors also make clear that, under federal law, online tools cannot entirely replace older systems: The ACA requires states to make enrollment possible over the phone, in person, and on paper, in addition to web-based portals.

Mobile Technologies:

State experiences with new technologies have had mixed results, and not all enrollees are comfortable with or have access to online services. Mobile technologies might be good ways to reach populations that are generally less likely to use the internet, such as minorities and low-income people.  The brief does not explore recommendations for how states might do so but use of smartphone apps and mobile friendly web portals should be considered.

In many cases, online technologies could supplement or complement telephone or in-person enrollment. For example, in Alabama, computer workstations are available for people who come to enroll in the state’s Children’s Health Insurance Program (CHIP) but who do not need intensive one-on-one attention.

Navigator Programs:

Community-based partners – which are required under the ACA through the creation of “Navigator” programs for every Health Insurance Exchange (HIX) – have played important roles in enrolling people in Massachusetts and Oregon.  Navigators in Exchanges might benefit from online technologies, either by directing enrollees to online systems or by using the systems themselves to track applications and access resources.

Federal Health Insurance Exchanges:

The brief does not address strategies for states in which the federal government, not the state itself, will establish and run Health Insurance Exchanges. “How Medicaid, CHIP and the state or federal health insurance exchange choose to integrate or coordinate services will have a tremendous impact on a consumer’s experience,” the authors note, though their recommendations appear targeted to states that establish their own exchanges.

So far, only 15 states and DC have indicated they plan to establish state-operated exchanges, according to the Kaiser Family Foundation’s latest count.  Another three states plan to share exchange functions with the Center for Consumer Information and Insurance Oversight (CCIIO), part of the Centers for Medicare and Medicaid Services (CMS).  Sixteen states are still studying options but many of these will likely be unable or unwilling to setup a state-run HIX by September 2013.  The remaining 16 states are not developing an exchange.  Therefore, CMS/CIIO may need to create and operate a federal HIX in 25 or more states.