“No wrong door,” a phrase coined to explain access to all the insurance affordability programs (Medicaid, CHIP and subsidized coverage through a Health Insurance Marketplace) through a single application process, is also often used to describe the different paths to enrollment. Beginning October 1, 2013, states are expected to allow individuals to apply online, over the phone, through the mail or in-person.

As of January 1, 2013, less than one-third of the states accepted new or renewal applications over the phone. One of the sticking points has been how to handle signatures, which are required for new applications but not at renewal. Wisconsin was one of the first states to implement “voice recorded signatures,” which are stored as mp3 files in the individual’s electronic file. Of course, this requires technology and the ability to interface a state’s telephone system with its electronic eligibility and enrollment system.

Given the Affordable Care Act’s requirement for multiple paths to enrollment, states have been awaiting further guidance from CMS on telephone applications. An FAQ released by CMS on August 9^th offers these guiding principles:

• States must be able to gather data over the phone in sufficient format to be transferred electronically. States have flexibility in developing their processes for telephonic applications but the process must “gather data in a sufficient format that is accessible for account transfer to the appropriate insurance affordability program.” For example, an applicant could be interviewed and the responses entered by an intake worker or call center representative in an online version of the single streamlined application.
• States must be able to accept a telephonically recording signature at the time of application. All new applications must be signed under penalty of perjury as required by federal Medicaid law. States like Wisconsin and Virginia can maintain their current practices of audio recording voice signatures.
• States must be able to provide a record of the complete application to applicants. States are encouraged to record all telephonic applications via an audio file or through a written transcript of the session.
• States should send a receipt confirming the telephonic exchange via electronic or paper mail based on the applicant’s preference. This communication must “include key information for applicants, including but not limited to the application summary, the eligibility determination summary page, a copy of the attestations, rights and responsibilities, and the submission date of the signed application.”

The Q & A did not specifically address processing renewals by phone, although it is likely that these principles apply. While it’s fairly straightforward for a call center representative or eligibility worker to conduct an interview over the phone and input the responses directly into the online application, the big question is whether states will be ready to handle telephonic signatures or send a confirmation of the telephonic transaction to the applicant by January 1, 2014. Such steps require technology interfaces and telephonic applications could be another area where states will develop temporary “work-arounds” until the systems development catches up.

By the way, the FAQ answers a number of other questions about ACA implementation including MAGI-based eligibility, renewals in the first quarter of 2014, pregnant women’s coverage, movement of the stairstep kids from CHIP to Medicaid, and the enhanced 75% FFP for eligibility system operation. For ACA implementation connoisseurs, it’s worth a read.