The Affordable Care Act brought the promise of affordable coverage to many lawfully present immigrants who are ineligible for Medicaid and CHIP due to longstanding immigrant eligibility restrictions. But, despite the overarching goal of increasing coverage for immigrant families through the health insurance marketplace, many continue to face challenges when applying for coverage on healthcare.gov.

With the third open enrollment period now complete, enrolling the remaining eligible but uninsured will become more challenging. In order to continue to make progress, we will need improved systems that make the application process work better for individuals with more complex situations—like people in immigrant families—who are eligible for marketplace coverage but remain unenrolled.

Our new report, Getting Enrollment Right for Immigrant Families, provides a roadmap that the federally facilitated health insurance marketplace (FFM) can use to smooth the path to enrollment for eligible citizens and lawfully present individuals living in mixed immigration status households. The FFM has already made some important improvements—including reductions in error screens, additional prompting about the need for applicants to provide immigration document numbers or Social Security Numbers; and a more refined notice and process for people who need to provide additional documentation in order to get premium tax credits. Our roadmap—summarized below—includes five priority areas for improvement and detailed action steps the FFM can take.

 #1: Refine the FFM’s immigration status and citizenship status verification protocols and processes.

 Even when valid document numbers are entered for immigrants who are eligible, the electronic verification through SAVE may not be successful. Recommended steps to improve the verification process include:

• conducting technical testing to identify the circumstances that lead to the inability to input or verify document numbers;
• instituting a second step to resolve a data-matching problem before triggering the inconsistency period even if applicants appear eligible for Medicaid or CHIP based on income and other factors;
• continuing to communicate the importance of inputting document; and
• ensuring a path to affordable coverage for individuals who have an ongoing immigration status-related data matching issue.

In addition, many immigrants who are not eligible for Medicaid or CHIP are being routed unnecessarily to the state Medicaid agency. Recommended steps to smooth out the process include:

• improving Healthcare.gov’s ability to discern differences between immigration statuses that qualify for Medicaid eligibility versus Marketplace eligibility; and
• involving stakeholders in developing solutions.

#2. Improve communications and expedite the resolution of inconsistencies. When immigration or citizenship status cannot be immediately verified, an inconsistency period is triggered. A key problem with the inconsistency process is difficulty in communicating effectively with affected applicants. Recommended steps to expedite the resolution of inconsistencies include:

• improving communication with those in inconsistency periods;
• expediting the resolution of inconsistencies when adequate documentation is uploaded during the application process; and
• continuing to improve timeliness and overall performance of the mail-in document center.

#3. Develop an alternative process to confirm identity. The ID proofing process is one of the first steps in applying for coverage on Healthcare.gov. Although not an eligibility requirement, in order to proceed with the online application process, a household contact filing the application must correctly answer personal questions derived from his or her credit history and other information. This protocol poses an immediate obstacle for immigrants and citizens alike when there is limited or no credit history or other demographic information available because the system cannot generate needed questions. Action steps to improve the ID proofing process include:

• identifying circumstances when calling Experian is not useful and bypassing this step for those applicant;
• expediting the review and approval of uploaded identity documents;
• permitting authorized assisters, with appropriate training, to attest to an applicant’s identity and upload documentation for the case record;
• expanding the list of documents that can be used to confirm identity; and
• providing an alternative online application that retains the advantages of applying online but does not share protected personal information.

#4. Boost resources for communication in languages other than English and Spanish. Language access is a common barrier in working to improve coverage rates for immigrant families. Although an estimated 25 million people in the U.S. are limited English proficient (LEP), the FFM provides the bulk of its written and online information only in English or in some cases just English and Spanish. Steps to improve communication include:

• translating notices so that LEP applications and enrollees know when and how to take action;
• providing in-language assistance through the FFM call center in more languages than Spanish;
• allowing assisters to provide interpreting directly or through onsite interpreters when calling the FFM call center permitting assisters to pre-schedule appointments with interpreters; and
• targeting assister resources to organizations that work to enroll immigrant and LEP communities.

#5. Improve the customer experience for both assisters and applicants, including refining the process for resolving complex cases. The FFM is intended to operate in a sophisticated technology environment where online systems connected to electronic databases determine eligibility in real time. However, immigrant families, and the consumer assisters who help them apply for health coverage through the FFM, continue to face problems that often requires a human touch. Promising action steps to improve the customer experience include:

• dedicating a specialized unit in the FFM call center to resolving complex cases for immigrant families;
• providing functionality for the FFM call center to access the application to better manage and resolve complex cases;
• creating workflows for casework and sharing processes with stakeholders;
• providing additional training tools to the assister community;
• continuing to provide resources for application assistance; and
• continuing to promote an environment of transparency and problem-solving with stakeholders.

With the close of the third open enrollment period, and the fourth open enrollment period beginning in only about 8 months, now is the time to lay the groundwork to make sure the promise of the ACA is accessible to all.

Support for this report was provided by a grant from the Robert Wood Johnson Foundation.