Toby Douglas November 8, 2011 National Association of Medicaid Directors

1. California’s Enrollment Future: Reflections on Federal Guidance and Work on the Ground Toby Douglas November 8, 2011 National Association of Medicaid Directors

2. California’s Response to the Medicaid Eligibility NPRM

3. Coordinating California’s Responses Met regularly with Health Benefit Exchange, CHIP program & HHS Agency Convened meeting with stakeholders (e.g. consumer advocates, providers) to provide high-level review of the proposed regulations and hear reactions and concerns. Submitted comments jointly & transmittal letter directs questions to specific lead program

4. Overview of Response to Medicaid Eligibility NPRM Eligibility Simplification Electronic Verification/Program Integrity Inter-Program Coordination Information Gaps and Ambiguities 4

5. Simplification and Streamlining of Eligibility • Substantial progress made with the Medicaid eligibility NPRM, especially considering the breadth of Medicaid changes within ACA • Supportive of simplifying and streamlining eligibility criteria, categories and processes • Landmark opportunity for states to reduce complexities and burdens which have hampered Medicaid programs for some time

6. Simplification and Streamlining of Eligibility • NPRM exhibits some tension between simplification theme and the competing aim to maintain pre-ACA coverage continuity in Medicaid • Clarification needed around state-selected min/max MAGI thresholds & ability to align coverage among the post-2014 vertical scheme of subsidy programs • Requesting the ability to further simplify/streamline programs on an individual state basis, in furtherance of the themes and intent of the ACA

7. Shift to Predominantly Electronic Verification • Cautious optimism for reliance on electronic data sources, ex parte reviews and self-attestation (in lieu of documentation, limited redeterminations, no status reporting, etc.) • High expectations for the effectiveness of the federal hub and supplementary state data sources that are not yet concrete • Contingencies - where electronic systems falls short, States require the ability to apply proven program integrity methods • Other issues of note: no signature requirement; furnishing of benefits “promptly and without delay”; “reasonably compatible” standard

8. Coordination with Exchange & CHIP • With expanded subsidized coverage and MAGI, the NPRM appropriately places significant emphasis on coordination among post-2014 insurance affordability programs • Must maintain a stable, accurate and cost-effective alignment of coverage programs, while minimizing churning

9. Coordination with Exchange & CHIP • One major area of uncertainty = scenarios posing the potential for concurrent eligibility under multiple programs (e.g. Medically Needy) • Other identified issues of note: addressing coverage gaps; mixed households; individuals declining subsidy determinations

10. Related topics not yet addressed Single state application and criteria for supplemental forms Benefit implications (benchmark and essential health benefits) Presumptive eligibility and transitional medical assistance Post-2014 program integrity tools available to States Post-2014 performance standards Topics requiring more detail MAGI conversion specifics Non-MAGI Medicaid and inter-program coordination Ability for states to optimally align coverage among post-2014 public programs Extent and character of information via federal hub, and expectations for accompanying state data sources Finalized menu of FMAP methodologies and specific techniques to be employed Topics Currently Posing Informational Gaps

11. Recommendations for Next Steps States need final regulations & guidance soon in order to inform planning, procurement and implementation. Specifically: • Prioritize maximum state flexibility & administrative ease • Promote state-specific solutions and innovation • Timely receipt of interrelated guidance and needed clarifications • Close coordination and collaboration with states in finalizing policy directives and options • Realistic expectations for implementation efforts and milestones

12. California’s Planning for the Enrollment System of the Future

13. California’s Goals for the Enrollment System Creating statewide enrollment system for all coverage programs California Affordable Coverage Enrollment System (CACES) Consumer-friendly, seamless, state-of-the-art Leverage and/or modernize state & county legacy systems

14. Planning & Stakeholder Engagement • Stakeholder workgroups with consumers and small businesses • Participating in UX2014 project with IDEO • Vendor interviews • Learning from Innovator States

15. On-Going Coordination for Enrollment System Joint DHCS, Exchange, MRMIB project team for shared enrollment system development RFO for system currently in development Short timeline for RFO release, review and contracting Create governance structure across Exchange, DHCS, MRMIB and counties