Eligibility and Enrollment Systems: An Advocate’s IT Toolkit

Efforts to improve public coverage programs have long been stymied by the prevalence of outdated IT systems that are the source of numerous consumer issues from confusing and conflicting notices to lost eligibility records to inadequate data to measure program performance. Meanwhile the state of technology and web-based services has advanced significantly, leaving many Medicaid systems in the dark ages. New technology is needed to not only support consumer self-service and program evaluation but also to make government work better – more efficiently and cost-effectively. Spurred by the need to implement the ACA’s new Medicaid rules and procedures and motivated by significant federal funding, states are moving forward in developing or adopting state-of-the-art technology, at least for their Medicaid programs. This is a critical juncture for consumer advocates to engage to ensure that the systems being developed today not only resolve the problems we have worked long and hard to remedy but also make it easy for consumers to connect to coverage.

The reality for many consumer or policy groups, however, is that IT systems advocacy represents new and potentially daunting territory, particularly for those with limited IT technical knowledge. To help advocates become more familiar with key consumer issues as states enhance or replace their current eligibility systems, Julie Silas of Consumers Union and I teamed up to create a new resource “Eligibility and Enrollment Systems: An Advocates IT Toolkit.” It provides background information, questions to ask about key IT system functions and features, and strategies that advocates can use to ensure that these new systems work well for consumers and promote streamlined access to health coverage. The toolkit is designed to be useful regardless of whether your state will be operating its own exchange, using a federally-facilitated exchange (FFE) or entering into a state/federal partnership model.

Included in the toolkit is more detailed information on these top consumer issue areas:

  • Consumer ease-of-use
  • Help for consumers with special circumstances
  • Getting help from the call center, navigators, or other assisters
  • Real-time eligibility
  • Seamless coordination between Medicaid, CHIP and the exchange
  • Health plan comparison and enrollment
  • Renewal and retention
  • Privacy and confidentiality
  • Appeals and due process
  • Data to evaluate program performance

With overloaded advocacy agendas in this fast paced healthcare environment, we know how challenging it is to stay on top of all of the demands on your time. Yet early and ongoing intervention from consumer advocates is needed to ensure that the important policy and procedural decisions embedded in a state’s IT infrastructure are made with consumers in mind. We hope this toolkit will help focus and accelerate your efforts on these critical issues in the coming months.

Tricia Brooks
Tricia Brooks is a Senior Fellow at the Center for Children and Families