CLS advocates for fair Health Insurance Exchange

On August 11, CLS Staff Attorney Kristen Dama provided the following testimony at a forum convened by the Pennsylvania Insurance Department regarding how to best implement Health Insurance Exchanges in Pennsylvania.  

Community Legal Services (CLS) thanks Commissioner Michael F. Consedine and the Pennsylvania Insurance Department for hosting public forums to permit stakeholders to present ideas on the establishment of a Health Insurance Exchange in Pennsylvania.

For more than forty years, CLS has helped thousands of low-income Philadelphians with legal problems by providing them with advice and representation in non-criminal cases, advocating for their legal rights, and conducting community education to inform them about the laws that affect their lives.  CLS also engages in legislative and administrative advocacy on behalf of its clients.  CLS’s Public Benefits Unit works to ensure that low-income Philadelphians have access to public health insurance and other benefits.

In recent months, CLS has been happy to work with the Pennsylvania Health Access Network, a statewide coalition of organizations working to protect high quality health insurance coverage and to expand coverage to the uninsured, to develop a Joint Position Statement for Implementing a Health Insurance Exchange.  The Position Statement outlines recommendations for establishing a Pennsylvania-run Exchange that functions as a marketplace for affordable, accessible coverage for individuals and families.  Rather than reiterate the principles contained therein, we simply note our endorsement of the Position Statement and urge Pennsylvania to incorporate its principles if and when it establishes a state-run Exchange.

CLS believes that implementation of the Affordable Care Act (ACA) creates an unprecedented opportunity to provide comprehensive health insurance coverage to low-income Pennsylvanians while, at the same time, addressing historical, systemic barriers to public health insurance access.  To that end, we focus our comments on how a Pennsylvaniarun-Exchange would be able to function best in concert with Medicaid and other public health insurance programs.[i]

Ensure that Enrollment Processes Benefit Public Health Insurance Applicants:The ACA contemplates that a state’s Health Insurance Exchange will provide a way for individuals and families to learn more about and apply for both private health insurance programs, with or without subsidies, and public health insurance programs like Medicaid and the Children’s Health Insurance Program (CHIP).  The Exchange will screen health insurance consumers for all programs and steer them to the program or programs for which they are eligible.  Public health insurance applicants will comprise a sizable portion of the Exchange’s users:  by one estimate, Pennsylvania’s Medicaid program is expected to grow by 685,000 newly eligible recipients beginning in 2014.  If the ACA’s vision of “one-stop shopping” is to be realized for allhealth insurance consumers, Pennsylvania must ensure that a state-run Exchange works as seamlessly for public health insurance consumers as it does for private consumers.To fulfill the Exchange’s promise as an entry point for public health insurance consumers, we urge Pennsylvania to: 

  • Provide clear, consumer-friendly information on public health insurance programs and program rules alongside similar private health insurance information.
  • Establish a common application for all health insurance programs, as envisioned by the ACA’s “no wrong door” policy.
  • Allow applicants for health insurance programs to apply for a broad range of public benefits at the same time, including Supplemental Nutrition Assistance Program (formerly food stamp) and Low-Income Home Energy Assistance (LIHEAP) benefits, by building onPennsylvania’s groundbreaking COMPASS online application system.
  • Ensure that an online application system will allow applicants to scan and upload required documents.
  • Ensure that applicants who lack access to the internet or who have limited computer literacy may apply for public health insurance programs in person or by telephone or mail.
  • Ensure that the application process for public health insurance programs, as well as all communications to health insurance consumers, meets the needs of consumers with disabilities, low levels of literacy, and limited English proficiency, consistent with federal law.
  • Seek permission from the federal government to streamline Medicaid eligibility rules by relying on sampling to determine how many Medicaid applicants are newly eligible, and by eliminating asset tests and adopting the Modified Adjusted Gross Income System for all Medicaid applicants.
  • Capture the minimum amount of information to make eligibility determinations by relying on data sharing across Pennsylvania agencies and with the federal government to verify income and citizenship and immigration status.
  • Draw from existing public health insurance program data (for example, from the CHIP and SelectPlan for Women programs) to enroll newly eligible populations in Medicaid using the “Express Lane Eligibility” authority granted by federal law.
  • Ensure that the Pennsylvania agencies tasked with overseeing eligibility determinations (currently, the Department of Public Welfare for Medicaid and the Insurance Department for CHIP) have appropriate staffing and infrastructure to process applications, seek documentation to the extent required, and manage inquiries and appeals from applicants or recipients.
  • Ensure that families with members who are enrolled in different public and/or private health plans may align their coverage and reapplication dates and otherwise coordinate their coverage.
  • Streamline reapplications using state-of-the-art prepopulated electronic and/or paper reapplication forms.

Incorporate Stakeholders with Medicaid Expertise

Pennsylvania has a sizable population of public health insurance recipients:  as of June 2011, more than 2.3 million Pennsylvanians were enrolled in Medicaid, and another 200,000 children were enrolled in CHIP.  To meet the needs of these recipients, a broad range of community health providers, social service agencies, legal and policy organizations, and recipients themselves have developed in-depth, historical knowledge ofPennsylvania’s public health insurance programs.  In addition to working closely with the State Medicaid Director, we encouragePennsylvaniato incorporate the voices of these community-based experts during the planning for and operation of a state-run Health Insurance Exchange, as contemplated by the ACA and proposed federal regulations.

Specifically, we encourage Pennsylvania to:

  • Ensure that the Exchange Board includes the State Medicaid Director or his designee, as well as other members with in-depth knowledge ofPennsylvania’s public health insurance programs.
  • Convene an advisory committee to the Exchange Board to ensure that community-based experts and other stakeholders with knowledge of public health insurance programs have formal, regularly-scheduled opportunities to share their expertise while the Board plans for and operates the Exchange.
  • Maintain ongoing communication and coordination with community-based experts, irrespective of their membership on the advisory committee, to ensure that Board considers and incorporates their perspectives as it plans for and operates the Exchange.

Provide Comprehensive Consumer Assistance and Navigation

Pennsylvania’s Medicaid system is an extraordinarily complex network of myriad eligibility categories, each with its own rules and requirements.  CLS knows firsthand that many eligible recipients would not otherwise qualify for Medicaid without assistance from a legal representative or social service provider.  While we are optimistic that the ACA will eventually simplify the Medicaid system, we anticipate that its initial implementation will prove to be confusing and frustrating for public health insurance applicants, particularly for those applicants who have not previously applied for or qualified for Medicaid, or who face barriers like physical or mental disabilities, low levels of literacy, or limited English proficiency.

The ACA requires state-run Health Insurance Exchanges to fund Navigators that will provide health insurance consumers with fair and impartial information about their health insurance options, and to facilitate their enrollment in health insurance programs.  While the ACA does not expressly require Navigators to provide consumers with assistance in applying for public health insurance programs, we implorePennsylvaniato task Navigators with this role, and to take additional steps to ensure that consumers are able to seek public health insurance successfully.

In particular, we urge Pennsylvania to:

  • Require Navigators to provide public health insurance consumers with comprehensive information and enrollment assistance, consistent with the assistance that they provide to private consumers.
  • Fund an independent consumer assistance program comprised of community-based experts statewide that have in-depth, historical knowledge of public health insurance programs and close ties to the diverse communities in which they work.
  • Appoint consumer ombudsperson, within an existing state agency, who is staffed adequately, reachable via a free public hotline, and tasked with fielding and addressing concerns and complaints from public health insurance consumers and their advocates.
  • Conduct an education and outreach campaign to underserved communities that uses Pennsylvania’s Cover All Kids campaign as a template and relies on new (social networking) and old (print, radio, and television) media and contacts with community- and faith-based organizations and schools.
Kristen’s full testimony is available here.

[i] Our comments echo those of Medicaid advocates in other states.  See, for example, comments provided by Medicaid Matters New York, available at


One Response to CLS advocates for fair Health Insurance Exchange

  1. Lenard Athels says:

    I have been having real troubles on my health insurance. These insurances do not cover for all my medical needs.

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