Study of Health-e-App Public Access Health-E-App Public Access: A New Online Path to Children s Health Care Coverage in California RESEARCH BRIEF 4 JULY 2013 Background Health-e-App is a web-based application that was originally designed for enrolling children from low-income families and pregnant women in the Healthy Families Program or screening them for Medi-Cal. The California HealthCare Foundation (CHCF) and the California Endowment supported its development, in partnership with the Managed Risk Medical Insurance Board (MRMIB), the California Department of Health Care Services, MAXIMUS, and Social Interest Solutions. Health-e-App was pilottested in San Diego County. Since 2000, CAAs and other professionals have used Health-e-App when they help residents apply for health coverage. A self-service version of the tool, Health-e-App Public Access (HeA PA), was launched in December 2010 to enable applicants to use it independently via the Internet. In January 2013, California closed new enrollment in the Healthy Families Program. The state continues to process HeA PA applications for Medi-Cal for Families. Perspectives on HeA PA from Certified Application Assistants Adam Dunn, Dana Petersen, and Leslie Foster This brief is the fourth in a series about the first year of California s Health-e-App Public Access (HeA PA) online enrollment system, following its introduction in December 2010. HeA PA caught on quickly with applicants, accounting for 20 percent of all applications submitted to the state processing center in 2011. Slightly more applications (about 22 percent) were submitted through the online accounts of certified application assistants (CAAs) or other professionals who prepare applications for clients; the rest (58 percent) were submitted on paper. Recent federal guidance encourages states to maximize self-service online enrollment under the Affordable Care Act (ACA). To gain insights about barriers to the use of self-service online enrollment tools and the potential role enrollment assistants could play in raising applicants awareness of such tools, we asked CAAs for their perspectives on HeA PA. We conducted telephone interviews with 23 CAAs, located in all regions of the state, who regularly submitted online applications in 2011. On average, these CAAs said they had seven years of experience in their positions and helped complete about 45 online applications per month. How much did CAAs know about HeA PA in 2011? The CAAs we interviewed were aware of HeA PA. Most recalled hearing about the new application option when it was first introduced, through the Healthy Families newsletter, their supervisors, meetings of service providers, or email announcements. 1 CAAs, however, were not familiar with outreach efforts on behalf of HeA PA: most CAAs did not know how applicants might have learned about HeA PA and none were familiar with the online outreach campaign that the state conducted to raise awareness of HeA PA among lowincome families (July to December 2011). Did CAAs make families aware of HeA PA or encourage them to try it? Although we had thought busy CAAs might tell clients about the new application system or even encourage some to try it, many CAAs said they did not tell applicants about HeA PA. Likewise, in a survey conducted for this study, only a few HeA PA applicants said they learned about HeA PA from a CAA (1 percent). The CAAs we interviewed cited several reasons for not referring clients to HeA PA: Incompatibility with their organization s mission. As one CAA noted, CAAs are supposed to help people... Those of us that are here to help aren t going to say
What do CAAs do? The CAA program began in the late 1990s as a way to provide enrollment assistance to families applying for Healthy Families. CAAs are affiliated with enrollment entities (EEs), which are typically health care clinics, insurance agencies, community organizations, city or county agencies, or school districts. Although CAAs work in an array of agencies and settings, their basic job responsibilities are the same. They help families apply for or renew coverage; explain health care benefits; and provide impartial information about health, dental, and vision plans. CAAs interact with clients in person or, more rarely, by telephone. 2 To become certified in their role, CAAs complete a webbased training and pass a certifying examination offered by Healthy Families. They can refresh their knowledge of the CAA role, as well as Health-e-App, through on-line review modules, but they are not required to do so. Healthy Families compensated EEs through a pay-per-enrollment system to encourage coverage of uninsured children at various times since the program s start; however, this system was eliminated in 2009 as a result of state funding cuts. Hey, you can do this online. Instead, we are going to help. Others said families that contact CAAs want our help or depend on us and that it would be inappropriate to refer them to the self-service application. In addition, CAAs said their agencies did not ask them to promote HeA PA to clients or train them to help clients use HeA PA if asked. As one CAA reported, They never told us to let clients know about it [HeA PA]; so no, I don t ever tell them about it. Perceived applicant barriers. CAAs said that most of their clients lack Internet access or computers, have low computer literacy, and often have language barriers that would make it difficult to use HeA PA successfully on their own. This is in stark contrast to data gathered from HeA PA users, who report using computers regularly (75 percent said they use the Internet daily and more than 90 percent have broadband access at home or work) and prefer communicating with Healthy Families in English. 3 Although HeA PA is available in English and Spanish, many CAAs said that their Spanish-speaking clients who have low computer literacy or limited education still might have difficulty using the tool. Whether this perception is correct, few applicants used the Spanish version of HeA PA in 2011. 4 More client difficulties or errors. Some CAAs thought clients would have difficulty uploading required documents, understanding income eligibility, or completing applications with complex family or custodial situations. Some CAAs believed that HeA PA applications would be more likely to be incomplete or denied; so they were reluctant to recommend the tool. As one CAA noted, When they try it on their own, they often miss questions, or they do something wrong. Another said, I personally feel that it should be mandatory to go through a CAA for assistance. That way there is a higher probability of the application being approved, versus [having] missing information or [being] denied. (In fact, HeA PA is programmed to prevent empty fields or invalid entries, but missing documentation can still be a problem. In 2011, 64 percent of HeA PA applications included required documentation, compared with 79 percent of assisted-online applications and 61 percent of paper applications.) Some CAAs did refer or encourage clients to use HeA PA. They did so when clients were too busy to attend office appointments, did not have time to complete the application with the CAA, or lacked transportation. A few CAAs referred applicants to HeA PA when their own work schedules became too busy, or when applicants did not want to continue waiting in the office for their appointments. But these instances were rare. Did HeA PA change any aspects of CAAs work? The CAAs we interviewed said the introduction of HeA PA affected their day-to-day work minimally, if at all. As one CAA noted, I think we expected [to see] a bigger impact [on requests for help] than we did with people being able to do it on their own, but I think that just goes back to the fact that people really like the assistance to make sure it s done right. Similarly, CAAs said the types of support they provided to applicants generally did not change after the introduction of HeA PA. We noted in the first brief that the volume of CAA-assisted applications did not change meaningfully with the introduction of HeA PA, confirming CAA reports that their jobs did not change. CAAs said they believed that applicants strong preferences for in-person assistance were one reason their workload was not affected by the introduction of HeA PA. As one CAA 2 Perspectives on HeA PA from Certified Application Assistants July 2013 Issue Brief 4
said, People trust us. We have done it already. They know that we know how to do it. Another CAA thought that the strong name recognition of the CAA program in California explained its continuing attraction to applicants: They [families] know about the CAAs and they just come to us. They would still want a CAA to do it. Did the lack of CAA referrals to HeA PA reflect a missed opportunity for increasing the number of self-service online applications? If, as the CAAs we interviewed thought, most applicants who seek CAA assistance need or prefer it, then the lack of CAA referrals to HeA PA did not reflect a missed opportunity. CAAs believed, though we do not have interview or survey data about CAA-assisted applicants to confirm, that many of their clients would not have been able to complete a HeA PA application successfully. If true, abandoned or denied applications would have been more common, which is not in the interest of applicants or the state. A clearer missed opportunity might be applicants who apply on their own using a paper application without knowing an online option exists. (In 2011, nearly 150,000 paper applications were submitted to the state processing center; about 8 in 10 were prepared without CAA assistance, according to the Healthy Families Program Data Warehouse.) The Healthy Families website and outreach materials list the availability of online enrollment options, but paper applications did not indicate the availability and benefits of an online option, including prescreening for eligibility. Although it can be procedurally difficult to amend application forms, adding such information to paper applications or instructional materials could encourage more people to apply independently over the Internet. Does California s experience with self-service and assisted online applications have implications for the state s implementation of the ACA? The self-service and CAA-assisted online application options seem to complement each other in meeting the needs and preferences of different types of applicants. HeA PA applicants were frequent Internet users, had access to computers at home or work, and were likely to have some college education. 5 Although we do not have comparable information about CAA-assisted applicants, the CAAs we interviewed believed their clients face multiple barriers to using online enrollment tools, including a lack of Internet and computer access and literacy barriers. To accommodate state Medicaid expansions and enrollment through health insurance marketplaces under the ACA, states are expected to maximize use of self-service online applications. 6 Indeed, as we reported in the first issue brief, the total number of applications increased notably in the first year of HeA PA, while CAA-assisted volume remained steady, suggesting that applicants sorted themselves into appropriate pathways. To help achieve this balance under ACA, outreach and enrollment strategists should be proactive about making both applicants and enrollment assistants, who will play a pivotal role in Medicaid enrollment in California and other states, aware of the various application options. In addition, some applicants who receive assistance with their initial application could renew their coverage independently online, so raising awareness of renewal options is also important. 3 Perspectives on HeA PA from Certified Application Assistants July 2013 Issue Brief 4
What can California do to promote the most efficient use of self-service and assisted online enrollment and accommodate applicants needs and preferences? To better help applicants choose an application method, the state should promote connections between enrollment assistants and self-service application tools. The CAAs we interviewed played little or no role in raising awareness of self-service enrollment in Healthy Families. However, given their regular interaction with clients, enrollment assistants could play a key role in providing information about all application methods. To promote the best possible use of the different application options, the state could consider the following options: Cross-promoting all application options. Applicants should have complete information on all the ways to apply for coverage and get help doing so. Outreach materials, application instructions, and paper and online applications should include such information. Making enrollment assistants knowledgeable about self-service online tools. In our interviews, few CAAs had more than a basic understanding of HeA PA, even though it mirrors the online program they use daily. Increasing enrollment assistants familiarity with self-service tools might decrease their hesitation in recommending them. It should also improve their ability to assist self-service users should they be asked for help. Helping outreach workers and enrollment assistants make appropriate referrals to online self-service tools. Research suggests that even applicants randomly assigned to a self-service pathway report a positive experience, but taking into account applicants characteristics and the enrollment setting will maximize the suitability of referrals. 7 For example, states could equip enrollment assistants with a short screening tool to identify good candidates for self-service online enrollment or renewal based on computer access, language, literacy, and other facilitating factors. Because CAAs work in diverse settings, screening applicants might not always be in line with a customer-service orientation (for example, for applicants in walk-in settings); however, when EEs schedule appointments for busy enrollment assistants or when enrollment assistants provide information about renewal, those could be ideal times to screen applicants. EEs may also want to consider providing access to self-service kiosks for this purpose. Many of the CAAs we interviewed were averse to recommending HeA PA because of their desire to help applicants; however, providing targeted recommendations for self-service tools is a way for enrollment assistants to give applicants greater flexibility in how they enroll in insurance. 4 Perspectives on HeA PA from Certified Application Assistants July 2013 Issue Brief 4
Endnotes 1 Healthy Families used email announcements and articles in a CAA newsletter to alert CAAs to the launch of HeA PA. Most CAAs we interviewed reported awareness of HeA PA through one of these sources. 2 See [www.healthyfamilies.ca.gov/ees_caas/reference_manual.aspx] for more information about the CAA role and responsibilities. 3 See Issue Brief 2 in this series: Applicant Characteristics and Experiences. Available at [www.mathematica-mpr.com/health/health-e-app.asp]. 4 See Issue Brief 1 in this series: An Overview of the First Year. Available at [www. mathematica-mpr.com/health/health-e-app.asp]. 5 See Issue Brief 2 in this series: Applicant Characteristics and Experiences. Available at [www.mathematica-mpr.com/health/health-e-app.asp]. 6 Centers for Medicare & Medicaid Services. Guidance for Exchange and Medicaid Information Technology (IT) Systems. Version 2. Baltimore, MD: CMS, May 2011. 7 A study for the California HealthCare Foundation that randomly assigned a small sample of applicants to different enrollment pathways found that most applicants assigned to online self-service had a positive experience. Applicants with computer or literacy barriers, however, found the experience more challenging. This study did not report whether their applications resulted in coverage: Perry, Michael, Mary Slosar, and Naomi Mulligan. Enrolling in Medi-Cal: The Consumer Experience. Oakland, CA: California HealthCare Foundation, February 2012. Available at [http://www.chcf.org/publications/2012/02/enrolling-medical-consumer-experience]. Accessed November 7, 2012. ABOUT THIS BRIEF This brief is one in a series that Mathematica Policy Research is producing with support from the David and Lucile Packard Foundation and CHCF, and in partnership with MRMIB. This brief draws on interviews with 23 CAAs who completed more than 50 HeA applications in 2011 (out of 229 CAAs who met this criterion). The CAAs we interviewed were affiliated with health care providers (eight), health insurance agencies (five), nonprofit advocacy groups (six), and local units of government or school districts (four). A small number of the CAAs we interviewed used One-e-App, another online benefit screening and enrollment tool, in addition to or in place of HeA. To select a geographically representative sample of CAAs for interviews, we stratified the 229 CAAs into five distinct regions of California and then randomly selected a sample of CAAs within each strata in proportion to their distribution in the population. We attempted contact with 51 CAAs, intending to interview the first 25 who responded to interview requests. In all, we completed 23 interviews. For more information, contact Leslie Foster, Mathematica senior researcher, at LFoster@mathematica-mpr.com. 5