new strategies like express lane eligibility and strategy that we call continuous removal which allow for the state to use data they already have to make enrollment process a lot simpler to avoid all of the needless documentation when the state already has the information and make the process a lot smoother from a consumer perspective. and along the lines of program management, we saw that our states had a clearly articulated vision that they developed and designed from looking at their own strengths and looking at their own challenges and opportunities. lori grubstein mentioned the diagnostic assessment and they were able to say this is where i need help and these are my goals. and from that they were able to define a clear vision. we saw amazing leadership, including from the two women you'll hear from today from alabama and virginia. we got to see our states using data to inform their program

management which made a tremendous difference for them and improve their strategies to coordinate across agencies and from the state to the local level in making sure their vision was shared and clearly communicated and articulated. states are going to drive consumer's experience of the aca and key lessons that come from what we observed from this work are first, that states are most successful when they can keep consumers in mind. that means not just the enroll ees walking in the door but the workers who are trying to engage and support their vision. and as well, the stake holders who are involved in that. all of these individuals and groups can be key supports and help the state achieve its goals. as i mentioned before, leadership and vision have been essential to helping our states. achieve their accomplishments so far. i think they are going to be really important in aca. we learned that nothing implements itself and that change particularly culture change is going to take time.

we had a famous saying in our program, let policy drive the technology so don't implement technology for technology's sake. definitely make sure policy is driving that but also important was making sure your policy is data driven and evidence based. that new technologies also require new approaches to work and work and processes. and also most importantly that the power of change is really driven by states owning the change and developing a vision for what they want to accomplish. so i look forward to talking more about that at the beginning of the conversation. >> great. tremendous insights, and alice, we look forward to expanding on those. we turn next to stan dorn who is a fellow at urban institute. what do we know about past experience in helping enrollment in college programs, not just what we learned about maximizing enrollment, but broadly speaking, past lessons that could be applicable now and help us understand the process of signing up people under the

affordable care act. >> thanks. we know a fair bit. we know it takes time. i'll give you an example from the children's health insurance program, which is now phenomenally successful in reaping its target population. and medicaid will enroll almost nine or ten eligible children. almost nine in ten, which is the high water mark of american social policy in these state-administered programs. but it took time to reach that. in years past they talked about disappointment in local participation. it took five years before they managed to ramp up and meet steady state levels. so we know it's going to take time. and the reason it's going to take time is that the aca is a program shared by the states and federal government. that's a good thing in that it

offers the possibility of experimentation. we're dealing in the aca with a lot of challenges that we've never undertaken before as a country. that means we need a lot of experiments to try out various approaches. some will succeed, some won't succeed, and the fact there is a lot of state flexibility means there will be a lot of lessons learned. over time, as we saw with chip, states will gradually migrate over to the most effective policies, but it doesn't happen overnight. i'll give you an example. in general, the few states and the few health programs at the federal level that have quickly enrolled lots of eligible people did so by eliminating the need for a consumer's complete paperwork before they enrolled in the coverage. in massachusetts, for example, in 2006, governor romney wanted to make sure eligible people were enrolled into the state's coverage, so folks did a data match with the state's old program, qualified people for premium coverage and enrolled

them. folks had a chance to pick a plan. those who didn't were automatically enrolled. that data-driven process was responsible for the enrollment in massachusetts that was launched in 2006. now, there are similar opportunities available under the affordable care act. they have said that states can use data from the food stamp program, the snap program or the information about the children of newly eligible parents who can use that data to automatically qualify people for coverage. in california, four states had enrolled in this, and those four states enrolled nearly a quarter of a million people, nearly 2 203,000 enrollments. but it's not even the 25 states in the district of columbia who are expanding medical capability.

it will take time for states to see, do we want to do this? i'm surprised that the first few were tweaked a little bit. we could have 500,000 rather than a quarter of a million people enrolled. but when you don't have one level of government firmly holding the reins, it takes time. it's natural, we all get upset, we get exercise over the initial numbers. we have a news media that has a huge news hold bill and they're looking for today's news. i think it's incumbent on us to take a deep breath, take a step back and realize, there's going to be problems early on, no doubt about it. but over time, i think there is every reason for optimism that just because the children's health care managed to enroll in eight states, so, too, should we be able to. >> now we'll hear from gretel

felton. she is director of the support division at the agency. tell us about your experience, gretel. what did you learn over the course of this program? how have those lessons now influenced your appreciation of the affordable health care act and the enrollment that has been in tandem with that? >> susan, thank you for allowing me to speak for alabama medicaid and the state of alabama. like you said before, it's on everybody's mind how these eligibility systems are important topics that anybody can think of in alabama. second to football. having said that, one of the things that we did that i'd like to talk about. first of all, in alabama, i would say when we started out in the enrollment project, we had a

very fragmented system. we had the alabama agency, and we had the alabama chip agency, and they had a different computer system. and then we had the department of human resources that served tana, snap and child care, and they were in a different agency, and they had three different systems. so our first thing was, we really need to get on these systems to talk. we decided we would do it in stages, and at first we just wanted them to speak to each other and learn the same language. so one of the things that we did to medicaid and chip is we got together and had an on-line application which both agencies used. so since 2004, we had had a joint on-line application with medicaid and chip, and it has served us very, very well. one of the things we wanted to do with express lane eligibility

is bring in the technology from the tanafin snap agency. if you don't understand what express lane eligibility is, it's a way that the medicaid agency can use the findings from another state agency to determine eligibility without having to get the paperwork from the individuals, as stan mentioned, and without having to do a separate eligibility determination. so the state of alabama decided that we would use the tanif and snap data. we started express lane eligibility in 2009 with medicaid renewal. we went on to, in 2010, with medicaid enrollments. and then in 2012, we did something exciting, which was automated express lane eligibility enrollments. i want to focus on that because that was the most exciting thing that we've done so far with the technology that we have. so what happens is every month

we do an automated match with the express lane agency, and if a person is on snap or tanif or both, then we will automatically renew their eligibility with the medicaid agency. right now in alabama that's working for children as well as adults in our plan for first family planning waiver. in express lane eligibility, we do about 43% of our express enrollments through our express lane. that's about 2500 enrollments we do each month, and almost 10,000 of those are done through express lane eligibility. that is very exciting for us because it cuts out work time altogether. the individuals just receive a notice saying their eligibility has been renewed through these data sources, and if they have any changes, report it to us.

what that does for us, it cuts out a lot of the administrative money that we have to pay out each month. it cuts out on husband sending a file, call them up, did you get my pact, did you get my pact, all those things, and it's very exciting. one of the things i would like to highlight is that express lane eligibility is supposed to sunset soon. here in alabama, we do not want it to sunset. we would love for that pho continue because that's an opportunity for states to have efficiency in their data management processes. it is something that we're excited about, and it also taught us to have a better relationship with our sister agency at the department of human resources. it works very well for them because they're excited, because when their snap clients get their medicaid renewals

completed each month, then they're in a better place as well. so it works very well for the whole state. we wanted to implement quicker business processes. we did a lot of process flows through maximizing the enrollment grant, and we wanted to make sure we were doing it right. most of the time -- there are three things that you need to look at in business processes: why, how and what? so in the technology end most of the time you're just thinking what do you have to do? in the policy end you're thinking how? how do i do it? but we were so thrilled and to grateful to have policy experts that were technical assistants for maximizing enrollment as to the question why? so when we began to do things,

we went to the field worker to talk to them and say, why did you do that? when we began to look at the why, we began to see there were some steps that could be cut out. there were some steps that weren't necessary. we fut that into -- express lane eligibility is the dimps between going on the superhighway and going into the city, just like here at washington, d.c., having to stop. >> thank you very much, gretel, and of course, gretel is und under -- so we have rebecca

mendoza, assistant to medical services. rebecca, tell us what you all learned in virginia during the course of this project? what were the measured takeaways for you, and how that is affecting enrollment today. we want to point out these two states, alabama and virginia, have not expanded their medical program. by and large now, we're talking about people visiting the extended. >> when we first started, we were mainly focused on building a data warehouse, and that was the focus of our grant. we had two eligibility systems very similar to alabama. we had one for 120 local departments of social services that administer our medicaid

program at the local level, and we had another one for our centralized chip processing unit. then in addition to that, we had our system of record for enrollment in medicaid and chip, our official record that also paid our claims. we really wanted to take data from those three different systems and combine it so we could do better analysis of what was happening with an enrollment and, really, better form our policy decisions. thankfully, the maximizing enrollment grant allowed us to do that. we did build our data warehouse. it's a wonderful fool for us. we have a great tool that we use. we're actually looking to use that in january, starting in january to monitor the enrollment process for the new hospital base for eligibility, which is very new in virginia. we don't have eligibility, so

this is a great tool we had gained through maximizing enrollment. it's going to help us through implementation of that piece of the affordable care act. it's just interesting enough the data warehouse did not end up being as big of a part of our grant work as we had thought it was going to be. actually, after the diagnostic assessment process that alice ask gr and gretel had both talked about, we really saw some opportunities, and we were stressed to think, okay, what other things can we do to improve enrollment and increase denials is one thing we really focused on. so we created other goals for our grant and work groups and really started to look at that. we were able to use our chip centralized processing unit. it comes with a test kitchen for

some of these technological strategies. so in the summer of 2010, we did a number of enhancements to our on-line enrollment process. we implemented a free, populated renewal so folks could go on line and access their information easily and renew easily. along with that, though, we implemented an electronic signature so we didn't have to send out a paper copy for them to do a wet signature and send back in. so we decreased the administrative denials for that. and we also added the function of verifications of that as well, again trying to decrease those administrative denials. then in the fall we added administrative renewal process for our chip enrollees.

that really gave us a lot of wonderful experience that is very applicable to what we're doing now at our call center. >> just say a word about what a telephonic signature is. >> it's where you record the person's signature. it's another form of electronic signature. you know, instead of having like a pen or something on line, you're verbally recording that you are signing the application. so that was a wonderful addition. one of the things is we piloted an expedited enrollment process

for newborns that are automatically eligible. they're called dean newborns for the policy folks. those are babies born to medicaid and chip moms and they automatically are eligible for a year. but we wanted to make sure they got enrolled in our system so the providers knew they were eligible. and so through this, we were able to enroll them in our system through the hospitals. we partnered with three hospitals in our state. it was so successful that now i'm going to announce we are implementing that statewide in january along with our state of eligibility. along with it, we also implemented some support strategies to build buy-in and get additional feedback from local workers to talk about the

process and what was problematic for them. and through that, then we clarified the ex parte policy. ex parte basically means that the worker can renew coverage without contacting the family just by looking at data sources already available to them to see if they're still eligible for their coverage. we did that. we also facilitated meetings with our local department of social services staff and the centralized processing unit staff to really focus on the account pace transfer process and streamlining that. and as a result of that, we implemented electronic communication forms to be able

to more smoothly communicate changes. one other important thing we did is we created a structure in our gra grant. as i said before, i said the thing that probably has helped us most to be able to implement the latest aca requirements is that electronic telephonic signature. we were able to implement a new call center for medicaid and chip that used experience that we gained over two and a half years to be able to offer that to our medicaid enrollees as well as our chip enrollees.

>> great. well, thanks to all of you. so what we've heard from alyice was that by acquiring and using new technologies, by adopting strategies that work, and by managing program change engaging leadership and also engaging staff at state agencies, all of these states involved in maximizing enrollment, and in particular, these two here, really did make enormous headway in the process of signing up people who were eligible for medicaid and chip coverage and keeping them on the rolls. as we heard from stan dorn in the chip and medicaid program and the policies of having these in place. as you heard from him, now those two programs have been able to enroll nine out of ten eligible children, really setting a high water mark for public program

enrollment in the u.s. as he also mentioned, other states built on this. massachusetts in the case of its state health reform built on some of these techniques of pre-qualifying and pre-enrolling people in coverage, and cns has enabled states to use the food program and the snap program now to do similar things in the states. as we heard from gretel felton, the combination of these things, express lane eligibility, bringing together fragmented enrollment systems, getting systems to talk to each other, all of those things have been extremely effective to getting them to be able to enroll many people and keep them on the rolls. i think you said 43% of renewal enrollments are done through express lane eligibility, and that is a big change. as you heard from rebecca, even

though the data changes and so forth, what really made the difference was the telephone signature changes, et cetera, and having state agency folks able to enroll in coverage without necessarily having to contact the families because they had data about other forms of eligibility, whether for snap or whatever, at their disposal and could reasonably assume that the people would continue to be eligible for medicaid and chip. so with that, alan, let me turn to you. cns wants performance measures to judge all these states by. it has actually published these measures. how are we going to be able to measure states broadly, not just these here, but others that are going to be achieving the goals and targets we have for medicaid and chip enrollment. >> i think that's a great question, and i think this is going to be an ongoing challenge, right, both for the

federal government to ensure that their investment in the medicaid and the chip program is paying off in terms of reaching the kids that are supposed to be enrolled, and for the federal government being able to monitor its own work, but also for the states to understand, are we achieving our goals? what are we trying to accomplish in providing these programs to folks and what are we doing as we're making these changes? i think that the cms performance measures are an amazing place to start. we saw, in the past month, cms put out its first national enrollment report showing medicaid and chip enrollment on a monthly basis in almost realtime compared to what it used to be, which was a six-month data lag at least. i think we're making incredible progre progress.

but i think there's probably a little bit more that could be done to support state measurement. the first and most important thing in any measurement effort is making sure there are measures. not just data collection, but understanding, what is our baseline for understanding what we want to accomplish here? so what percentage enrollment in a month is what we could expect or what percent retention are we looking for? so understanding we could look for targets based on that. for states especially, making sure they're defining their goals for performance. so having state's goals really inform, what do we want to measure? i was really interested in hearing rebecca say we want to use our data warehouse to measure what's happening in warehouses. that's a major change for states yet there is no required collection on that right now, but states are really going to want to know. there are other things the states could be doing, like tracking their disenrollments, making sure they understand why people are disenrolling and the

requirements maybe getting in the way of people staying on coverage. there are a variety of other key things states may want to look at, like tracking the questions or the issues that are coming in through the call centers, figuring out how many people are using translation services, which is a new requirement under the aca and figuring out how the special needs populations are also faring. we have amazing new data now on race and ethnicity that has to be tracked by the state as part of the application process, but none of the federal measurements at this point appear to be tracking that, and it would be great if the states and the feds could be using the information about race and ethnicity and demography to understand where they are. i think a number of states are using an integrateive process. they're looking at, how can we

enroll across programs, and figuring out how those states can also be reporting that back and sharing on a periodic basis. you know, how are we doing enrolling in snap and tanif and child care subsidies? it seems like a good opportunity. >> stan, i wanted to go to a point you had made. you mentioned the fact that a number of these states had used similar strategies to enroll people in the medicaid expansion population have succeeded in enrolling more than a quarter million people that way. but you also said you thought if those programs had been tweaked a little bit more, half a million could have been enrolled rather than a quarter million. what would these tweaks have been? >> they looked at their records and they said, who is getting snap food stamps and not medicaid, and who do we know is eligible for medicaid based on what we already have in hand through the snap program? they had all kinds of folks who had incomes well below the

medicaid threshold, and there was no other work needed to determine their eligibility. but what the states did was to send a mailing to all these folks and say, hi, congratulations, it looks like you're eligible for medicaid. we had some assistance from the food stamp program. all you have to do is fill out a piece of paper or telephone number and we can get you enrolled in coverage. so depending on the state, between, i think, 26% in oregon to 46%, something on that order, in west virginia responded to these mailings and signed up for coverage. which is an extraordinary level of responsiveness to a mailing, but it means more than half the people who we know are eligible for medicaid are not being signed up. this would always be problematic because it seems folks who should be able to access coverage and care are less able to do so, but it's even more problematic under the affordable

care act because many of these folks will be subject to a penalty if they don't enroll because many have in connection with above the federal income tax filing threshold. so what can we do to get these folks? all we have to do is look at what states have already done, states like louisiana and south carolina, which when maintaining acceptability, they didn't require the parents to fill out a piece of paper or even check a box on a form. they said, congratulations, your child is eligible for health coverage. you will consent to enrollment by having your child actively seek care. north carolina said once that happens, it's going to trigger managed care enrollment. you can pick a plan. if you don't pick a plan, we'll auto assign one to you. in louisiana, 18,000 kids were enrolled in the coverage in that

first year. something on the order of 28% of all new enrollees came in. in south carolina, they enrolled almost 100,000 children using this method. we just had published the national report on express lane eligibility, and a lot of folks said, well, you know, if we're not forcing people to fill out paperwork, do we really know that they know they have coverage? are we just using care? what our colleagues over at mathematics have found is there is almost no difference between a percentage of people who use coverage for kids who are enrolled using these highly streamlined automatic methods. a difference between kids who actually used care. so what this means is we can't highly streamline.

they would use the same strategies that maryland and louisiana had used instead of 46% response rate. we would have 9 to 100 of these folks signed up for coverage. the good news is, it's not a one-step coverage. you just heard the people from alabama or virginia, and if we saw that here, you would have a step-by-step process. the media coverage from the aca, oh, my god, what's happening now? is it a success? is it a failure? we're going to have problems. red oak, rebecca, have had problems around the country. when you've been hearing about it -- i know nothing about cars. all i want to know is i push here to get going and push here

for the brake. a lot of people will be able to enroll, we're not going, and we're going to be able to determine he will. i think we have a very exciting era in store, but we just have to be patient and recognize it's going to take time. >> so let me ask gretel and rebecca, you heard stan describe systems where people don't even have to enroll on paper, they don't even have to have a telephonic signature. essentially you could just show up with your child at the physician's office, and if you were eligible, that would be deemed an expression that you were consenting to enrollment. is that the next frontier for your states? do you envision yourselves going

that far? >> perhaps it did. it's just that simples well. i do want to just understand that rome was not built in a day, and the way we did express lane eligibility, i'm all excited when 10,000 cases on average per month. and you're saying. in the. it's hard to get systems is what it will take to get everybody working together to make it happen in different states. we have learned so much from the

other states from what they did. we learned a lot. cms had not set up a template. we have to do a state plan amendment to make these changes with the federal government. and they had not put a template out for their state plan. well, louisiana had made one. so we used theirs and sent it to cms and we got approved before they did. so anything can happen on your way to express lane automation. >> and that wasn't cheating? i'm just kidding. it sounds like an innovative approach. rebecca, what about you? what do you see will make enrollment even more eligible? >> i think the eligibility for virginia is going to be a big step forward because it is kind

of taking that leap and testifying information involving enrollment for folks. i think that, in partnering with the hospitals to make sure a full application is complete so we've got ongoing coverage for these individuals is important. but, you know, we don't want to just rely on folks going to the hospital and being uninsured and getting enrolled. so, you know, we will continue to look at options for us. i think the enrollment process that gretel has been talking about and sam has been talking about, there's some devil in the detail there about does your state really have two separate eligibility systems for those programs where you can actually do a data match and do the streamline enrollment for cms or not? and so virginia has some of those challenges.

but i think really where we're going to see a big bang for our buck is when we -- because virginia is a federal marketplace state. and when we really operationalize and smooth out that account transfer between the state and the feds, just like we have 12 and a half years of experience doing those handoffs with the centralized processing unit and the transfer services for medicaid, that took a long time to get that smoothed out. it's not 100% perfect, but it goes a long way, our work has, and i think that's been key in the future for streamlining enrollment in federally facilitated states. >> can i take up something you said about the hospital-based presumptive eligibility? all the technology we've been

talking about is just one way to eliminate paperwork for consumers. another way to eliminate paperwork is to have someone else fill out the paperwork on someone's behalf. that also has been the key in massachusetts, in 2006. so for hospital eligibility, this is a way for the hospital to harness the desire for revenue and use it to benefit consumers where the hospitals can easily fill out the paperwork on a consumer's behalf, get that person enrolled. rebecca makes a good point. we want to make sure that's not just covering the hospital's short-term bills. we want to make sure that gets views to make sure the consumer gets enrolled on an ongoing basis. but it's not just hospitals. it's also consumer-based hospitals where they're given grants to enroll not just their patients but also others in the community. and more broadly, the navigator program is critically important in determining the number of

people that will get enrolled. not everybody has a snap record that proves they're eligible for medicaid. a lot of people don't have that data in hand. not just about health coverage but from savings accounts. if you ask people to fill out paperwork, most don't and they don't get enrolled. on the other hand, if you have somebody who sits down and fills out the paperwork, someone will be not enrolled. there are different levels based based -- how many dollars were available relative to others per state, and it was just stunning. in the states with federally run exchanges, there is about 1/7 the number of application installers per uninsured resident compared with state runners.

-- to do administrative costs including signing up for coverage, but they've had to depend on congressional appropriations. to say the least, congress hasn't always been wildly enthusiastic in the last couple years about appropriating administrative dollars for the aca. some states will see -- in everything it's going to take time. but in the better states we'll see 3 to 5-year ramp. >> i want to go back to the point of changing work processing. i ask both of you, rebecca and gretel, to talk about the impact of state workers who are signing up people and retaining people in these agencies, in medicaid and chip. you mentioned that in some aspects, you reduced work loads

or reduced a lot of the busy work by taking away the need to constantly deal with paper, et cetera. you've also, in a way, given these workers more authority. you mentioned again the ex parte ability to actually look at the data and determine that it family, yes, indeed, is probably eligible and should be renewed. what's the sensibility within your agencies? do workers feel better about the way the system is working? do they feel they're more empowered to actually do their jobs? >> i'll take that first. i do feel like in alabama the workers are very excited and appreciative of the amount of work efforts that has been taken off of them because of the things that we've done. i do want to underscore that we still need medicaid workers and there are always the difficult cases, and that allows us to spend more time on the difficult cases that will take time, and we can complete the cases that we can through the simplified

processes. they do feel empowered to go in and do the work, and we take the time to look at what their processes are, and we take a look at what is unnecessary and give them more time to do the work they're doing. one of the things, i think, that rebecca mentioned was the newborn. we are also doing something with our newborns. what we are doing in alabama is that when a pregnant woman comes, we actually just go ahead and get a medicaid number for the number of unborns they have, and then when a claim is filed, it's an automatic process. so that helps the worker -- t, helps the state, that helps the hospital and the physicians, that helps everybody. i did also want to mention one group that no one talks about, and that's a new group called

the former group. what they will do in the future beginning very shortly is to send us a file of those individuals that they know about who will be eligible or who are aging out of foster care, and we can just put them on without any further ado. so the automatic processes are a win-win situation for everyone involved. >> rebecca? what will it change for the day-to-day workers within the agencies? >> yes. i'm sorry. i think it's a little bit of a mixed bag. any time you implement a new system, just that in and of itself is huge. there is new process work clothes, there is new -- just a learning curve of reporting that new system. but on top of that, we also

implemented a totally different eligibility process, you know, the rules for eligibility for medicaid and chip just completely changed, too. and so the workers are having to learn new policy, a brand new system. we have a brand new partner that we didn't have before, the federal marketplace. we've got a brand new application and so i think all of these things make it challenging we have just an excitement, i think, about putting federal data to their file electronically and take away some of that paper verification process we've had in the past. i think it's very exciting and i think it will be a great benefit to our enrollment processes. i think going forward in the spring when we start doing the new magi renewals, i think we'll

have additional -- >> let's just clarify for the audience what magi renewal means. >> magi is modified adjusted gross income, and that is the new methodology of policy for determining eligibility under the aca that aligns the insurance affordability programs through the insurance, medicaid and chip. so in the spring, we're not doing renewals under the new rules yet, but in the spring we'll begin to do that and using the new application. we were talking about ex parte. the aca has said that first you must do ex parte. if you cannot do ex parte, you can send out a partially filled out renewal form, et cetera. those are wonderful policy changes, however, since this data is a brand new application,

it's brand new data points, we're looking at tax filing status and all kinds of data we never used before in eligibility, we don't have that in our current data files. therefore, we must ask the family for that new data. and, therefore, we can't do ex parte for this first year for those folks. so it's another challenge for work processes and the workers. but once we get through that, i think it's going to be wonderful. >> great. well, we would now like to open this up to questions from those of you in the audience, those of you watching us on line as well as people who might be sending in a question from twitter. we have them roaming around the room with microphones. please identify yourself first by name or affiliation. if you have a direction for one

of our panelists versus another, please do so as well. let's start over here. >> i'm from the urban institute. there have been a number of examples of things that can be done for maximizing enrollment. i want to ask about the politics of this. there are people in certain states, and they're represented here, who are not in favor of expanding medicaid. as we know, in the past, making things difficult to enroll has been a way of keeping down the enrollment, and that was actually a policy goal of some people. i want to ask about the political change that's involved he here. how can states like your two states or louisiana or south carolina or oklahoma, i heard a bunch of states mentioned. how is maximizing enrollment become a politically accepted goal in those states?

the other thing i wanted to ask about is, is there any concern about enrolling people that are actually not eligible, and what the politics of that would be if you ended up with people getting enrolled that shouldn't be enrolled, and how does that concern play out in terms of trying to maximize expansion? >> let's break those questions into two. stan, why don't you talk about moving from a mentality of minimizing enrollment to maximizing enrollment, whether that's politically possible in many states. and alice, you take on the question of whether you enroll people who aren't actually eligible. >> the politics is tough. but it's more complicated than one might at first think. you have states where the highest selected official in the land is adamantly against the affordable care act, and publicly so, and yet you have public servants at every lefvel of the agency who make sure they

have law implemented the way it's supposed to be implemented. south carolina, for example, the government is adamantly against implementation, yet they have been one of the most innovative states in the country in taking children and getting them enrolled in the coverage. just remarkable things. oklahoma is also a state whose leadership has not been wildly enthusiastic actually pioneered a functional, realtime, on-line enrollment system well before the aca was first implemented. you have a lot of folks, like the two people you see in front of you, who are smart, creative, dedicated who are doing amazing work in the middle levels of the state agency regardless of what's happening on the top. the flip side is you have blue states that have saved money by making it hard for people to sign up. i remember cory davis, the governor of california, when he came into office he said, you know what?

we shouldn't be reassigning people every six months. all kinds of eligible people don't fill out the paperwork and they fall through because they're not eligible. and his budget proposal was, you know, we need to go back to those 14 months. the politics is complicated. we'll just unfolds. but at the federal level, there's now been a sea change. as gretel, and see if you have data on hand to define eligibility. if you. and even if we know you're eligible, go through an op is to kel case.

that's where we say you have the highest lefvels of government, and you have the folks further down that are doing great things for consumers. >> i want to expand but also add to what stan said. i think on the question about maximizing rome, i want to make sure we distinguish between expanding and maximizing enrollment. i think south carolina's governor has done a great job in terms of expanding, right? we are going to ensure that, 93% of the fpl for parents who are eligibility as we can to make it happen. i think that theme of good government and promoting efficiency is what has helped many of our states sell this. >> to their leadership. >> and i see nods and i know that's not the case.

good government is something everyone can get behind, and it should be something that should be a model for all states. in terms of the minimizing errors, we heard from some of our states. but what they did was they tested the. and they would roll out on a perish basis sort of, here's our small change. let's see what happens. what they found by this bit-by-bit implementation and then statewide implementation was very low. . they had very stroj performance, despite the thakt. they didn't have to volunteer every single line.

the other thing that's important is electronic verification and the new opportunity glg to happen in the aca. it's going to change. and i think that capacity is going to how long. they're looking at states' productivity, they're looking at states' in terms of who is as both, enrolling someone who is ineligible and not enrolling someone who is negligible. >> we have a question here in the back. let's take that and we'll keep moving around the room. >> hi, i'm rebecca out of cq.

i wanted to ask gretel and rebecca if you could quantify for me how many applications you're getting from the fmm are people who are either not eligible or people who are actually envold but -- evolved. >> at this point they have not rounded out the federal facility marketplace, which is what we use in alabama. at least the account managers, i thought toasted until they reach a maximum. so i don't have those numbers y yet. >> rebecca? >> we're in a similar situation. we're expecting to, i think,

receive the case transfers any day. we're in testing, too, i think, so we're in the final stages of that. but there are over 15,000 that we're expecting. i would expect that some of them will be folks who have already enrolled because of the process that the general marketplaces have set up where they're doing -- it's called a mec check, but it's the minimal central check to see if anyone is enrolled, they've got coverage. they're doing that on the back end of enrollment versus the beginning of enrollment. there are we're asking them to send some of the transfers or posts that are almost enrolled?

>> by the cases that they handled for two months, two-thirds were small state-based licenses. understandably, a lot of media is run on the. in the states that have an integrated process. the other one working to go for, and i think we can shift some of the focus toward the state-based mark marketplaces where we're going to see the best case scenario of aca involved. >> so for somebody who is already enrolled in medicaid and applies to reenroll, what happens?

that system. >> correct. it would be caught when they do a process file clear and they look to see if the person is already enrolled. i just want to point out, it's not only folks who are applying for themselves and are already enrolled. this process will happen in states like virginia where the parents are applying for exchange coverage for themselves, and they have to have their children, eligible children enrolled in medicaid or chip if they're eligible for those programs. so we believe there is going to be some of that going as well where the children are already potentially enrolled in our programs but we have to, you know, pre-verify that with the feds before the parents can get their exchange program.

>> we have a question over here. >> i'm clark ross with the american association on health and disability, and we're a new robert wood johnson funded grant project. we're a resource for the cns navigators on disability. so i would ask your experience with working. i didn't know if there was a lot of experience with this project, or a little experience, where you haven't gotten to that first. >> the group of individuals that are disabled, they would be in the group of that. we will be sending the state the

people to be eligible for chip and then the person on the application have indicated they are disabled and would like a full disability determination, as well as some other people that may have gotten an indication from the fsn that they're not he will vibl for to see disability advocates, the department of mental health and we meet regularly with that shoo r, or the people on disability is not difficult. >> when we were talking about the things we're doing, one of the things we do for people with disabilities, a lot of times their circumstances don't change

over time, so we do the auto mated renewal back for that. we uselyilities a lot. >> when we were looking at the renewal policy and refreshing it out again, the feedback we got from workers was that that population is the one they're able to use in the ex parte project no longer that the the. but i have colleagues that could probably better answer your question than i could. but we have made sure that we

have in our paper application, which is a version of cmr's paper application, we have a supplement so somebody can fill out the additional questions needed to determine ablong tif term care, and they could throw up the additional questions and determinations so they could. it's just like an indicator so the worker knows they have to follow up with that person to do the whole transformation. >> let's take a question from the front. we'll get a microphone over to you. >> thank you. howard glekman of the urban institute. you mostly talked about using

government entities to enroll people. i'm interested in non-governmental entities? for example, tax preparers. have you all thought of using them as a way to get people enrolled in exchanges? >> stan, why don't you start. >> yeah, i think tax are an enormously promising source of application assistance for lots of reasons. a few years ago we did some research to estimate among the uninsured the percentage who filed federal income tax returns, and we were surprised to find that 86% of the uninsured, including 75% of those with incomes below poverty, filed federal income tax returns. now, not all are legally required to do so. many do so to gain child tax credit or other refunds, but the tax preparers office is where a heck of a lot of the uninsured are going, and more than two-thirds of eitc claim man-to-mans, low-income

taxpayers, file with the aid of tax preparers, application assistants, and these are folks who are in the business of filling out paperwork for consumers, and they have in hand at the tax filing moment most of the information they are going to need to complete the application, and not only that, when you think about the motivation to enroll, something we haven't talked about today is the sort of unpleasant topic of penalties, somebody who's uninsured is going to be penalized, and the way the penalty is enforced is losing your tax refund, so when you're seeing the tax preparer is learning what the subsidies might be and in terms of thinking about, oh, my god, if i don't get insurance, i'm going to have to pay this penalty, so i think there's enormous possibility. that said, there's also challenges. you get most of the information you need from the tax return, but you need more. you need to find out what the income is right now in the case of medicaid, what the income is going to be during the course of the rest of the calendar year,

so you need to make sure people actually enroll into health coverage, so we don't know all tax preparers necessarily have the full skill set to enroll people in health coverage, but i think it's a enormously promising opportunity, particularly this year, because the open enrollment process into the exchange runs through the end of march, and we know that more than 80% of low-income tax preparers file a return by the end of march. as we're rethinking maybe after this first year we could rethink about changing the open enrollment and plan year periods so this incredible network of tens of thousands of tax preparers can be engaged year after year in helping people enroll into coverage. >> notwithstanding the enormous potential, stan, it is the case now there is no authority for tax preparers to enroll people in medicaid. >> not so, not so. the irs has come out and said if you want to use the tax data that you get from your clients and apply it for purposes of enrollment into health coverage,

here's the process that you go through. >> so they can do it on a voluntary basis. >> the second largest commercial for-profit tax preparer is very deeply engaged in this, jackson-hewitt, but there's a lot of work that needs to happen before these folks get all the information they need. >> i have a couple thoughts. i think stan did a great job outlining why tax preparers should be part of the mix, and i think we've heard a lot about their concerns about whether or not they are set up well to do that. i think there are a lot of other entities that are very involved that we need to make sure to flag. one is community health centers. i think the questioner talked about the government and the government is funding community health centers, but they are fek nickically nongovernmental agencies. they are the first point of service for a lot of this work and some of our states have done amazing work through partnering to sort of have them be not just the point of entry, but the

assisters in the application process. there's also potential, a lot of these programs that are serving, you know, low-income populations who are likely to be eligible through other programs like snap, like wic, free and reduced school lunch programs. we spent our entire program enrollment trying to figure out how to use that data in a realtime way to connect and have schools connect into the process of enrolling, so i think there's a lot of potential there and i think the next decade we're going to see a lot of innovation in that realm. >> all right. we have time for one more question. yes, right over here, if we could. >> hi, chad berman, health management associates. in your push to maximize enrollment, i was wondering if you've seen adverse effects on access to care or access through coverage, so benefits, networks, cost share?

>> well, what do we see so far, and again, these are two states that have not expanded the medicaid program, so now we're talking about signing up people who are already eligible. >> so far in the state of alabama, we have not seen any adverse effects, however, we do know that we have a long way to go in creating access for all the people and not just access, but we want them to have good care, and so that is one of the things that we are working on right now in alabama. we're rolling out regional care organizations, because you're right, it doesn't do any good to enroll them unless they are able to find a primary care physician, unless they are able to have a continuum of care, so that's one of the things that we are working on right now in alabama. >> i would say very similar comments. we haven't seen access issues related to our enrollment work under this grant or other

strategies, but virginia has recently expanded statewide manage care for the majority of our population. we're also one of the states that's doing the partnership with cms for the duals project, medicaid and medicare and that will be rolling out in 2014, and so we really use our managed care partners to leverage their networks. not all of them, but a good majority of them have commercial side of business, and, you know, they are able to do networking analysis and really fulfill that network requirement that sometimes even on the fee for service side it's harder for us, because we don't have all those tools and opportunities. >> stan, it certainly is the case that a number of states

that are expanding their medicaid programs are looking at new ways of organizing the care provided to people in medicaid. we have the example of oregon with coordinated care organizations. say a bit more about those states and how far along they are in this process. >> right. so, state medicaid programs have been historically an underappreciated hub of care innovation. and we're seeing that tradition continue, and when we think about the many newly eligible people who are going to enroll in medicaid in the states that expand eligibility, it's a challenge to make sure you have enough providers on the ground, but it's also a cliche and have an opportunity, but the only way i think we're going to be able to meet the increased demands for care is to reorganize care and not to have a bunch of solo physicians each heroically doing

what they have to do, but instead have physicians serve as captains of clinical care teams who engage nurses, who engage social workers, who engage community educators and that model both means we can leverage our physician resources to serve more people, improve quality of care, and slow cost growth. that's the direction we need to move. but just as we've been talking about enrollment, you certainly don't snap your fingers and create a new health care delivery system overnight. there are going to be plenty of challenges. the good news is, we're not going to be enrolling people as quickly as many thought we were, so the access to care challenges won't be as great as many people thought, but we're going to have time, and we're going to need to use that time, both to get eligible people enrolled and to make sure they get the care they need after they've actually received their card, insurance card, and have access to care. >> alice, you've mentioned the community qualified health centers and we're seeing a big

expansion of those centers. most are adopting the patient-centered medical home approach. that's going to be another important avenue, correct? >> right. that is 100% true, and i was actually going to mention, we've been doing a lot of work with state medicaid offices trying to develop them and strengthen them through work with the aca and even before the aca. to the extent people are interested in understanding what pioneering approaches states are taking, i would certainly encourage them to check out www.nashp.org. i think we've done a lot of research, and there is a lot of good information out there about how states are piloting this approach, where they use the medicaid program as the financing structure to support, as stan was saying, a more coordinated approach, and sometimes the chc is at the hub of that and sometimes it's more of a provider network approach, but there's a lot of good opportunities to learn. >> so we're going to give the last word now to both gretel and

rebecca. let me give you both a chance to talk to your two states, you get a chance to talk to 48 others and the district of columbia. what would you say to states who have not yet embarked on the process trying to maximize enrollment and maybe doing that in the future, what is the biggest takeaway you have for them, what's the number one idea they should keep in mind as they contemplate taking on this additional challenge, gretel? >> i would say a couple of things. first, good partnerships with agencies, with other states that have done it before that, you know, this is called maximizing enrollment lessons from states. you always learn the most lessons from failing, so most of us that have done it, we failed a number of times and you can just learn from our mistakes and go forth, and also that it is worth the effort to get folks enrolled, to get them enrolled quickly, and to get them enrolled without a lot of

effort, and they are very pleased with the process, and i just also want to say, again, that patience is something that we all need, because it does take time. and that people will appreciate it very much. >> and rebecca? >> and i would say what i've learned is that even though we have maximizing enrollment grantee states that just about every state is doing something or another working on this issue. we're not, you know, special in that. we just got to work together and really concentrate on this effort. but as gretel said, you can really learn a lot from other states, and, in fact, that's the reason i got distracted, because i got thinking about what gretel was saying about the former foster care children and what we could do in our state, so that really makes the difference, is

sharing those lessons and being able to have that dialogue between the states and what they've tested and tried. >> i do want to say that every state is different. what works for one state is not always the same that works for another state. it's not a one-size-fits-all kind of thing. it's something that's very different for each state, and states have to realize that and do what you do best. >> well, gretel, as you said, there are a lot of lessons to be learned from failure, in some instances, take note, healthcare.gov, but we also have lots of opportunities to learn from successes, and we've heard in the case of the eight states enrolled in maximizing enrollment, that there are plenty of those lessons to be had and to be applied going forward, so i want to thank the two of you, as well as you, stan, and you, alice, for walking us through all this on a very interesting and important discussion. i also want to say thanks to the robert wood johnson foundation and nash p. and urban for making

this briefing possible and encourage you who want more information about these programs to consult the websites of those organizations. thanks to all of you. thanks again to those of you for joining us today, and have a great holiday. [ applause ]