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Public Access to Online Enrollment forMedicaid and SCHIP

May 2003

Public Access to Online Enrollment forMedicaid and SCHIP

Prepared for CALIFORNIA HEALTHCARE FOUNDATION

by National Academy for State Health Policy

AuthorKirsten Wysen

May 2003

Acknowledgments

The National Academy for State Health Policy is a nonprofit,nonpartisan organization dedicated to helping states achieveexcellence in health policy and practice.

The Academy would like to extend its appreciation to thefollowing officials in five states who provided informationabout their online enrollment systems for Medicaid and theState Children’s Health Insurance Program (SCHIP).

GEORGIA: Jana Leigh Thomas;

MICHIGAN: Robert Stampfly and Sharon Costello;

PENNSYLVANIA: Pat Stromberg and Sundhar Sekhar, withDeloitte Consulting;

TEXAS: Jason Cooke and J. Pablo Bastida; and

UTAH: Chad Westover, Amy Bingham, and Anna West.

In addition, we would like to express our appreciation toClaudia Page and the California HealthCare Foundation fortheir generous support and assistance.

About the Foundation

The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improvingCalifornia’s health care delivery and financing systems. Formedin 1996, our goal is to ensure that all Californians have accessto affordable, quality health care. CHCF’s work focuses oninforming health policy decisions, advancing efficient businesspractices, improving the quality and efficiency of care delivery,and promoting informed health care and coverage decisions.CHCF commissions research and analysis, publishes anddisseminates information, convenes stakeholders, and fundsdevelopment of programs and models aimed at improving thehealth care delivery and financing systems.

Additional copies of this report and other publications can beobtained by calling the California HealthCare Foundation’spublications line at 1-888-430-CHCF (2423) or visiting usonline at www.chcf.org.

ISBN 1-932064-38-9Copyright © 2003 California HealthCare Foundation

http://www.chcf.org

Contents

3 I. Overview

5 II. Types of Online Enrollment Systems

Type 1: Online Enrollment with an Automated “Back End”

Type 2: Online Applications Submitted Electronically to the Program

Type 3: Online Application Assistance Tools

Type 4: Applications Available Online to Download

7 III. Overview of Five States Permitting Public Access

Georgia

Michigan

Pennsylvania

Texas

Utah

12 IV. Issues Related to Public Access

Security

Supporting Documentation

Signatures

Online Help and 1-800 Support

Application Status Availability

15 V. Implementation Challenges

Internet Connection Speed

Out-of-State Submission Prevention

Duplicate Applications

Credit Card Payment

State Agency Coordination

Family Composition

17 VI. Low-income Residents’ Access to the Internet

18 VII. Conclusion

19 Appendix

Innovative Ideas for Promotion

User Feedback and Surveys

Endnotes

4 | CALIFORNIA HEALTHCARE FOUNDATION

THE NUMBER OF STATES USING WEB-BASEDapplications to enroll individuals in Medicaid and StateChildren’s Health Insurance Programs (SCHIP) continues togrow. As of March 2003, at least eight states were operatingsome form of statewide online enrollment — California,Georgia, Michigan, Nevada, Pennsylvania, Texas, Utah, andWashington. In addition, pilot projects were underway inlimited areas of the state in at least eight more: Arizona, Florida,Hawaii, Indiana, Louisiana, Maryland, New Jersey, and WestVirginia. By the fall of 2002, a combined total of almost100,000 families in these states had applied for Medicaidand/or SCHIP coverage for their children using a state-sponsored Web site.1 Customer and staff feedback about online applications have been overwhelmingly positive.

Of the eight states operating online enrollment systems, sevenpermit public access. In these states, individuals as well as staffat community-based organizations can complete and/or submitonline applications. Individuals can apply from home, atpublic libraries, or other locations where they have access tothe Internet. A majority of the applications submitted in theseseven states come from individuals not from organizations.

California’s online enrollment system, known as Health-e-App,is the only state system that does not permit use by applicantsthemselves. This report, which profiles states that permitpublic access to their online systems, identifies opportunitiesfor California and for other states considering adopting anonline enrollment system.

Of the eight states operating

online enrollment systems,

seven permit public access.

I. Overview

This report provides detailed information aboutfive states that permit public access to onlineenrollment systems. Information about thesesystems was gathered through a phone surveyconducted by the National Academy for StateHealth Policy (NASHP) in March 2003. Thefollowing systems were examined:

■ Georgia’s PeachCare for Kids onlineapplication,

■ Michigan’s online application for MIChild and Healthy Kids,

■ Pennsylvania’s COMPASS system,

■ Texas’ eZ-application, and

■ Utah’s online application for CHIP.

Nevada and Washington were not included inthis examination; however, the models theyoperate are similar to others described here.Nevada operates a system similar to Georgia andMichigan, and Washington operates a systemsimilar in function to Utah’s.

The following information, where applicable, ispresented for each state:

■ Background and current statistics,

■ Security,

■ Documentation submission and the use of electronic signatures,

■ Implementation challenges, and

■ System benefits.

In addition, because states have taken differentapproaches to providing online enrollment, eachstate’s system is classified based on functionality.

Public Access to Online Enrollment for Medicaid and SCHIP | 5


THE FIVE STATES PROFILED IN THIS REPORT USEa range of Internet-based approaches to enroll individuals inpublic health coverage programs. While all states refer to theirsystems as an “online enrollment” or “online application,” theindividual functionality differs greatly across efforts. Below areclassification categories for describing and identifying eachstate’s system:

Type 1: Online Enrollment with an Automated

“Back End”

A Type 1 online enrollment system has an automated processto capture, save, and transmit the user’s data to the program’seligibility database. Security systems must be in place toprotect the transmission, storage, and retrieval of applicant’sdata. This approach offers administrative cost savings andimproved efficiency of the application and enrollment process.

The greatest efficiency is demonstrated in states that permitself-declaration of income and the submission of electronicsignatures, ensuring that the entire enrollment and notificationprocess can occur online. Georgia’s SCHIP program is one ofthe most efficient examples of this type of system, becausemost applicants can self-declare their income and electronicsignatures are accepted for enrollment. California, Georgia,Michigan and Pennsylvania are operating what could becategorized as Type 1 online enrollment systems, even thoughsignature pages and income documentation are needed inmany cases to complete the applications.

Type 2: Online Applications Submitted

Electronically to the Program

These online applications capture, save and transmit data fromthe user and deliver it to the program. The program staff thenprint the applications and process them as if they had beenmailed in. These systems require redundant manual data entryby the program staff. Type 2 systems do not have anautomated back-end linking user-entered data to the program’seligibility database. Users are notified electronically that theirapplication has been received, and sometimes of their tentativeeligibility. Official eligibility notification occurs through the

While all states refer to their

systems as “online enrollment,”

individual functionality

differs greatly across efforts.

II. Types of Online Enrollment Systems

mail. Utah, Washington and some Californiacounties operate Type 2 online enrollmentsystems.

Type 3: Online Application

Assistance Tools

In Type 3 systems, users enter their eligibilitydata into a Web-based application assistanceprogram that provides helpful information to theuser and flags errors. At the end of the process,users can be notified of their apparent eligibility,and they are instructed to print the applicationand submit it by mail. Texas operates a Type 3online application assistance tool.

Type 4: Applications Available

Online to Download

Applications are available online to download(PDF files), complete, and mail. Many statesmake a downloadable version of their applicationavailable online. This service eliminates the timeand cost of mailing out an application toprospective applicants.



THE FOLLOWING PROFILES OF STATE’S PERMITTINGonline access focuses on basic system information andfunctionality. Challenges and specific issues related to publicaccess are addressed in the following section.

Georgia

Web sitewww.peachcare.org/dehome.asp

Classification Type 1

Programs Medicaid for Children and SCHIP

BackgroundGeorgia’s online enrollment system was implemented in 2001as part of an overall effort to allow children applying by mailor online to become eligible during the month they applied,rather than waiting until the first day of the following month.

The online application was developed by the existing thirdparty administrative vendor for Georgia’s SCHIP program, theDental Health Administrative Consulting Services (DHACS).Development took four months and cost about $40,000.

Basic FunctionalityIn Georgia’s Type 1 system, the application is submitted in realtime. The data entered into the Web site are electronicallytransferred to a server hosted by DHACS. This server updatesthe vendor’s eligibility database on a separate server every twominutes. Such frequent updating permits families to call thetoll-free number immediately after submission and the custo-mer service representative will have complete access to theirnewly created account.

After submission, the parent receives a tentative eligibilitydetermination, such as “Your child is potentially eligible forPeachCare” or “Your child does not appear to be eligible forPeachCare” with the reason for denial. After submission, theapplication is checked against the Medicaid eligibility database,to see if the applicant is already enrolled in Medicaid, and theState Health Benefit Plan records for state employee matches,since state employees’ children are not eligible for SCHIP.

In Georgia, 97 percent of

online applications are

received from individuals,

with three percent from

community organizations.

III. Overview of Five StatesPermitting Public Access

http://www.peachcare.org/dehome.asp

Usage StatisticsBy March 2003, after two years in the field,60,262 applications had been received electroni-cally. In 2003, Georgia has received about 1,500applications online per month.

Surveys indicate that 97 percent of these onlineapplications are received from individuals, withthree percent from community organizations,including county offices, outreach organizations,clinics and hospitals. Over half of the applicantsapplying over the Web were eligible for SCHIPand 42 percent were found eligible for Medicaid.

Michigan

Web sitehttps://eform.state.mi.us/michild/intro1.htm



BackgroundMaximus is Michigan’s third party administratorfor the SCHIP program, MIChild. Accelio hasdeveloped other Web-based applications for thestate of Michigan. During 2001, MichiganMedicaid and SCHIP staff worked with bothcompanies to develop an online enrollmentsystem. A pilot program in seven sites began inFebruary 2002 and statewide implementationbegan in June 2002.

Basic FunctionalityApplicants fill out their information online. Aftersubmission of the information, eligibility is deter-mined and reported within two to three minutes.A signature form and premium coupons arecreated as PDF files, which the applicant candownload and print. Signatures and premiumpayments must be mailed in within 30 days.Individual applicants qualifying for Medicaid arenot entered into the Medicaid database until thesignature form has been received. Applicants

applying with the help of health departments ortrained agencies are entered into the Medicaiddatabase, since the community agencies assistwith the follow-up for signatures.

Usage StatisticsMichigan receives about 2,000 onlineapplications per month. The total number ofonline applications from June 2002 to March2003 was 9,395. About half of the onlineapplications are filed through communityagencies and half from individuals.

Pennsylvania

Web siteswww.compass.state.pa.us orwww.healthcare.state.pa.us


Programs Medicaid, SCHIP, food stamps, cash assistance, long-term care, home andcommunity-based services, school lunch, low-income heat subsidies, and childcare subsidies

BackgroundCommonwealth of Pennsylvania Application for Social Services (COMPASS) representsPennsylvania’s statewide initiative to make stategovernment more electronically accessible and tomake access to a range of government servicesmore centralized. The Department of PublicWelfare (DPW, which oversees Medicaid,welfare, and child health) and the InsuranceDepartment (which administers Pennsylvania’sChildren’s Health Insurance Program [CHIP]and adultBasic) partnered to implement theonline system in 2001. Deloitte Consulting wascontracted by DPW to develop multiple appli-cations for an array of state services. COMPASSwas expanded in an iterative fashion to incremen-tally add Web-based access to state social andhealth services over a several year period.


https://eform.state.mi.us/michild/intro1.htm

http://www.compass.state.pa.us

Launched with Medicaid for Children andPregnant Woman and SCHIP in October 2001.By February 2003, food stamps, cash assistance,adult Medicaid, Medicaid for disabled workers,long-term care, and home and community basedservices applications were added. In addition,screening (tentative eligibility determination) isavailable for those services and school breakfastand lunch programs. In late 2002, COMPASSalso was expanded to include a communitypartner portfolio view, allowing advocates andcommunity partners to easily enter applicationdata and track applications in the pipeline. Low-income heat assistance and childcare subsidies areplanned additions for the fall of 2003.

Basic FunctionalityPennsylvania’s Type 1 system, COMPASS, hastwo components: screening and applicationmodules. The screening component providesapplicants with tentative eligibility information,e.g. “It appears that you may be eligible foradultBasic and cash assistance. We encourage you to apply.”

The applicant can then use the applicationcomponent to apply online for the programs theyselect, although some still require face-to-faceinterviews. The application component transmitsthe applicant’s data to up to four state agencies,depending on the services selected by the appli-cant. Applicants are notified that the applicationhas been received and they can track their appli-cation through the eligibility determinationprocess. Providing the ability for applicants totrack the progress of their applications wasintended to reduce calls and contacts at state and county service agencies.

Usage StatisticsIn February 2003, there were 17,000 visits to theCOMPASS Web site. 2,700 applications weresubmitted online; 95 percent were from individ-uals and five percent were from communitypartners. Of the 2,700 applications that month,39 percent were for Medicaid, 31 percent forfood stamps, 19 percent for cash assistance, eightpercent for adultBasic, two percent for CHIP,and less than one percent for long-term care andhome and community based waivers.

Pennsylvania reports that 75 percent of usersapply from home, and 13 percent more applyfrom a relative’s home. Eight percent apply fromlibraries, three percent from school, and onepercent from the workplace. Less than onepercent apply from a hospital, career link office,Internet café, or other location. COMPASSapplications represent about three to five percentof all Pennsylvania Medicaid applications.

Texas

Web sitewww.texcarepartnership.com



BackgroundThe Texas SCHIP and Medicaid programs have a Web-based application assistance tool availableon their Web site. This online application walksapplicants through a 32-page screening tool andprovides estimated eligibility to the applicants atthe end.

The eZ-Application is an application assistancetool; it provides prompts and additional informa-tion to users as they enter information on theWeb. It does not offer any back end connectivityto the eligibility system.


http://www.texcarepartnership.com

Basic FunctionalityOnce an applicant completes all of the data entryand information screens, a tentative eligibilitydetermination is provided. The applicant mustthen print the application, sign it, includeincome documentation, and mail it in. No dataare transmitted across the Internet to the stateand no data are stored.

StatisticsIn 2002, about 10,000 applicants used the eZ-Application Web site, while 1.1 millionapplicants submitted paper applications withoutsuch assistance. About 60 percent of paperapplications were complete when submitted ascompared to 90 percent of eZ-Applications. Anew reporting system for 2003 statistics for Web-assisted applications is currently being developed,but results are not yet available.

Utah

Web sitewww.health.utah.gov/chip


Programs SCHIP and Utah’s Primary CareNetwork (PCN)* *a Section 1115 research and demonstration waiver expansionpopulation of low-income adults

BackgroundUtah residents have been able to apply for Utah’sChildren’s Health Insurance Program (CHIP)online since June 2002. The application wasdeveloped in conjunction with a broader, state-wide effort to make state services available on theInternet. Utah’s SCHIP program worked withthe state’s existing Web site developer to add theirelectronic application to the state’s Web site.

Basic FunctionalityUtah operates a Type 2 system. Applicantsprovide eligibility information online and thedata are transmitted to a secure server hosted bythe contracted Web site developer. Applicants arenotified that their application has been received.

Based on the applicant’s zip code electronic appli-cations are sent to one of 31 regional offices.State eligibility staff are assigned passwords toaccess the system. The state employees in theregional offices print the application and processthe application as if the application had beenmailed in. There is no electronic population ofdata fields: data from the printed application are manually entered into the eligibility system.Applicants are notified by phone or mail of theirtentative eligibility status and if verificationdocuments are needed.

Usage StatisticsResidents of Utah may apply for the CHIPprogram only during open enrollment periodswhich are normally two weeks long. Onlineenrollment was available for the first time duringthe June 2002 open enrollment period and 1,122applications were received online, representing 18 percent of the total applications. During theNovember 2002 open enrollment period, 4,191applications were submitted online, representing45 percent of total applications.

Out of 13,666 applications received for thePrimary Care Network expansion since July 2002,3,347 (24 percent) were submitted online.


http://www.health.utah.gov/chip


FROM THE OUTSET, THE FIVE PROFILED STATESdesigned their online enrollment systems primarily to allowindividuals to apply on their own, rather than with the assist-ance of community organizations. This section focuses onissues such as security, signature collection and documentationcollection and the approaches states have taken to allowindividuals to apply independently for health programs overthe Web.

Security

States with Type 1 systems that have an electronic link betweentheir online application and their eligibility databases have toput standard security measures in place to protect how theinformation is transmitted, stored and retrieved. Issues relatedto security do not differ for individuals accessing systems andstaff from community-based organizations. Georgia, Michiganand Pennsylvania’s security measures are reviewed below.

Georgia’s Security MeasuresOne of Georgia’s biggest concerns when implementing

their system was around security of their system — for all users,individuals and staff from community organizations. Georgiauses two servers in its online enrollment system. Users enterdata that goes to the first server. Every two minutes data areuploaded to a second server that contains their eligibilitydatabase. The servers are protected with firewalls and 128-bitencryption. Additionally, no income or account informationare stored on the first server collecting the applications. Thesedata are continually moved from the server accessible throughphone lines to a secured server that is only accessible throughthe internal network.

Georgia initially did not store any information on the firstserver. However, after implementation, the state found thatsome parents quit the application half way through, intendingto complete it at a later time. With no data saved on the server,parents were unable to pick up where they had left off, leavingthem frustrated and confused. The system since has beenmodified to assign application numbers and passwords andallows the applicant to complete a partially finished applicationat a later time. Georgia is also planning to use VeriSign — the

Issues related to security do

not differ for individuals

accessing systems and staff

from community-based

organizations.

IV. Issues Related to Public Access

secure, online credit card processing service —to begin accepting credit card payments forPeachCare for Kids.

Michigan’s Security MeasuresMichigan’s system uses three servers.

The first collects information from the user in ahttps environment. The first server transmits datato two other servers behind state firewalls.

Pennsylvania’s Security MeasuresFor Pennsylvania’s screening component,

which provides tentative eligibility determinations,applicants use the system “anonymously.” No dataare saved in the screening component; applicantsmust move to the application component if theywish to apply. There are no major security issuesrelated to the screening component because dataare not sent to the eligibility databases.

In the application component, Pennsylvania uses Web- and database-level security measures.COMPASS uses a 128-bit secure sockets layer(SSL) encryption system and a Netegrity layerbetween the Web server and the eligibility datasets.COMPASS feeds into eligibility databases in fourseparate Pennsylvania state agencies and uses thesame security approach for all four. Data are savedin COMPASS for 90 days.

Supporting Documentation

Georgia’s Medicaid and SCHIP programs acceptself-declaration of income. Documentation ofimmigration status must be submitted for non-citizen children.

In Georgia, premiums are required for childrenage six and over. Most families with childrenunder six can complete the application completelyover the Web. Families with older children aretold at the end of the online application where tomail their premiums so that coverage can begin.Applications requiring citizenship documentationor premiums must have the paperwork submitted

within 45 days of the application for coverage tobe backdated to the date of application.

In Michigan, self-declaration is accepted forincome and age of children, but alien status ofnon-citizens and proof of other insurancecoverage must be documented.

Pennsylvania requires income documentation(and a signature page, see below) to be mailed in following the electronic application. Texasrequires that income documentation be mailedwithin 60 days of mailing the application. Utahrequires income documentation if the applicant’sincome cannot be found in the state’s workforceservices database. Eligibility workers in Utahcontact the applicant and notify them what typeof documentation is needed before coverage can begin.

Signatures

Most states require written signatures for theirMedicaid applications (with a mailed in signaturepage), while some states accept electronicsignatures for their SCHIP programs (Georgiaand Utah).

Georgia can determine eligibility immediately for U.S. citizen SCHIP applicants who are underage six, since no premium is required. Ratherthan supply a written signature, applicants agreeto rights and responsibilities when they click“submit” at the end of the application. ForGeorgia Medicaid applications, the written signa-ture must be submitted prior to the six-monthrenewal for the child to maintain coverage. Thisapproach is consistent with Georgia’s policy forthe submission of Social Security Numbers; theyare required but will not cause a delay in theinitial enrollment of the child.

Michigan and Pennsylvania do not accept elec-tronic signatures. Families either can print off thesignature page and send it in within 10 days, orwait to have the form sent to them. To increase


the efficiency of COMPASS, Pennsylvania isconsidering seeking federal and state approval for a two-step electronic signature (the applicantsubmits identifying information and an e-mailaddress and the program e-mails a password tothe applicant, who uses the password to verifytheir identity) for COMPASS.

Texas requires a printed signature page for bothSCHIP and Medicaid. Utah accepts an electronicsignature for SCHIP, consisting of the userretyping their name and clicking the “submit”button. By doing so, the user attests to theaccuracy of the submitted information andaccepts certain rights and responsibilities. In Utah Medicaid, eligibility workers mail a Medicaid addendum for signatures anddeclaration of assets.

Online Help and 1-800 Support

The five profiled states use their regular 1-800number for their programs to provide assistanceto Web site users. Community partners do nothave a separate support number to call. Thesestates report that most of the calls related to the Web site come if the system is down. Fewindividuals call needing help completing theapplications, which are intended to be intuitiveand self-guiding.

Michigan anticipated that they would receive lots of calls about their online application fromindividuals related to printer problems, hardwareor software issues, but this did not happen. Mostof the questions they received had to do withhow to answer specific questions in the applica-tion, what to do if a connection is lost, or whythe system did not respond after the informationwas submitted.

Texas provides a one to three paragraph “Needhelp?” box on each page of their Web-basedapplication to provide assistance to users.

Application Status Availability

Most of the states do not allow users to track thestatus of their application online. Of the statesprofiled for this report, only Pennsylvania allowsindividuals and community partners to trackapplications. Individuals can track their applica-tion through the eligibility determination processand community partners can track applicationsthey have submitted in the last six months onbehalf of applicants. Pennsylvania also provides a “Power User” module to allow communitypartners to quickly complete data entry forapplications rather than having to scroll throughmany screens.



EARLY EXPERIENCES WITH ONLINE ENROLLMENTsystems led to anticipated and unexpected challenges. Theprofiled states provided additional information about challengesand innovations they found during implementation of theironline systems.

Internet Connection Speed

Georgia reports that for home users with slower modemspeeds, they had to balance the goal of creating a commercial-quality site with using smaller and less complex graphics. Theyalso had a challenge to make their system compatible witholder versions of Internet Explorer and Netscape, and for userswith MacIntosh computers. Netscape users see a button at thebeginning of the application indicating “Netscape users clickhere,” and they are guided to a separate system.

Out-of-State Submission Prevention

Originally, Georgia did not put a check in the system to blockzip codes or residential states that were not in Georgia. Inaddition to cluttering their database with non-state residents,they heard from some non-Georgia residents who hadcompleted the entire application and were frustrated to berejected at the end. Now, if a parent enters a state other thanGeorgia or a zip code that is not in the state, they are imme-diately informed that the children must reside in Georgia to be eligible.

Duplicate Applications

In the first few months of the Web site, Georgia received someapplications for children who were already enrolled inPeachCare. The state discovered that parents who wished toreport a change of address for an already enrolled child wereunintentionally completing and submitting a full applicationon the Web site. The Web site has been modified to add asection to provide updates to existing accounts.

Pennsylvania faced challenges

creating one Web site portal

that could screen and provide

applications for programs

administered by four state

agencies.

V. Implementation Challenges

Credit Card Payment

Georgia is now working on the development ofcredit card payment capabilities for the initialapplication and ongoing enrollment. This hasmany issues involved, including credit cardcompany fees and additional concerns aboutsecurity.

State Agency Coordination

Pennsylvania faced challenges creating one Website portal that could screen and provide applica-tions for programs administered by four stateagencies. For example, “earned income” could bedefined three different ways across three programs.COMPASS is tailored to collect and transmit thespecific set of data elements needed for eachprogram. The programs, in turn, have tried tointegrate their programs and definitions as muchas possible. Pennsylvania also had to provideadditional documentation to obtain supportfrom the state’s central technology authoritybefore they could begin.

Family Composition

Texas reported their greatest challenges were to create the programming to take multiple,complex family compositions into account forSCHIP and Medicaid.



SOME POLICYMAKERS HAVE STATED CONCERNthat online applications will be used primarily by relativelyhigher income Medicaid and SCHIP applicants, and have beenworried that many low-income residents do not have adequateaccess to computers. Most states have not found strongevidence to support this.

In Georgia, mailed in applications tend to consist of about 25 percent who are eligible for Medicaid and 75 percent whoare eligible for SCHIP (and thus slightly higher income). Atthe same time, 42 percent of Georgia’s online applications arefor Medicaid, and 58 percent are for SCHIP. This divisionsuggests that many lower income applicants do have accessto — and are using — the Internet.

In addition, Georgia found that the average income of onlineenrollees is 120 percent FPL, a lower average income level thansome had anticipated would make use of online enrollment.

Texas analyzed a small sample of their Web-based applicationusers over eight months in 2002 and found that 35 percent of online applicants had incomes over 150 percent FPL; 65 percent had lower incomes. These figures did not differmarkedly from those of applicants who submit paper forms:26 percent of the regular paper applicants had incomes over150 percent, and 74 percent had lower incomes.

Utah’s marketing staff notes that a U.S. Department ofCommerce report from 2000 (Falling through the Net, TowardDigital Inclusion) documents increases among traditionallydisadvantaged populations in their access to the Internet.2

Georgia found that the

average income of online

enrollees is 120 percent FPL,

a lower average income level

than some had anticipated

would make use of online

enrollment.

VI. Low-income Residents’Access to the Internet


The trend among states implementing online enrollmentsystems is to allow individuals to access these Web sites ontheir own. While Michigan reports that half of their onlineapplications are from individuals and half are from communityorganizations, the other four states receive a vast majority oftheir electronic applications from individuals applying forcoverage without assistance. Further, the study indicates thatmany lower-income applicants do have access to — and areusing — the internet.

California, the only state with an online enrollment systemthat does not permit public access, has the opportunity tolearn from the states profiled in this study. In addition, statesthat might wish to implement an online enrollment system inthe future can learn from the experiences of those who haveopted to allow individuals to access the system directly:

■ Security issues related to public access and communitypartners do not differ. States use encrypted datatransmission, secure log-on procedures, firewalls and otherstandard measures. No state has reported any securitybreaches and applicant fraud was not identified as an issuefor any of the profiled states.

■ The use of electronic signatures for Medicaid and SCHIPapplications allows states to maximize efficiency. States mayneed to include a fax or mail-in submission option.

■ When applicants know that they can apply online, fromhome, they are more likely to complete applications.

■ The so-called “digital divide” is not as much of a barrier asanticipated and states are finding that many of their lowerincome applicants have access to the Internet.

■ Limiting the documentation requirements to only thoserequired by Federal law (e.g. citizen status for non-citizens)and making use of back end systems to confirm income andemployment status greatly enhances the efficiency of theautomated systems.

When applicants know that

they can apply online, from

home, they are more likely to

complete applications.

VII. Conclusion

Innovative Ideas for Promotion

Most states market their online enrollmentsystems extensively through community-basedorganizations, rather than the media. All the statesreference their Web site on their paper applicationsand other materials. Only one of the profiledstates is carrying out a marketing campaignmaking extensive use of advertisements.

Georgia kicked off their Web site with a pressevent with then-Governor Barnes in May 2001.Georgia today markets the Web site primarilythrough schools. In August 2001, PeachCare for Kids fliers were distributed to 1.6 millionstudents in their school registration kits. Duringthat month, 2,321 applications were submitted,three times as many as were submitted theprevious month. In September 2002, Georgiasent out two million fliers to new students again.

Michigan distributed information about theirWeb site to all the libraries in their state. Michiganalso works with local health departments andhospitals to encourage people to apply online.

Pennsylvania is currently reaching out to localagencies and community organizations through-out the state to promote COMPASS. Texas relieson community partners to provide applicantswith information about the Web site.

Due to the need for statewide notice of openenrollment periods, Utah markets their Web sitemore actively than the other states. They began anew identity branding campaign for their CHIPprogram in November 2002, right before the openenrollment period. The Web site is mentioned onall of their advertisements. In their current tele-vision spot, the url and phone number are on thescreen for half of the 30-second ad. They havealso placed many ads on radio stations.

User Feedback and Surveys

Customer feedback collected from individuals by state’s operating online enrollment systems has been overwhelmingly positive. Georgia andPennsylvania collect feedback information in abrief voluntary survey at the end of the theironline applications. Michigan, Texas and Utahhave not done so.

GeorgiaApproximately half of the online

applicants fill out the survey at the end of theapplication. The Georgia staff have learned thatthe PeachCare for Kids 1-800 number is theirlargest referral source. Often when a parent callsto request an application, the customer servicerepresentative lets them know about the Web site.When the parent is on the phone requesting anapplication, they are ready to act and they oftengo right to the Web site. The Web site capitalizeson this moment and allows them the opportunityto complete the process, rather than just requestan application to be mailed. Other referrals comefrom friends and family, advertisements, healthcare providers, and schools.

The Georgia survey also revealed that themajority of applications are submitted from theapplicant parent’s home computer. In addition,23 percent of respondents reported that theywould not have applied that day, if at all, had it not been for the Web application. The ease and accessibility of the Internet applicationprompted parents to apply and the conveniencewas appreciated.

Some quotes from Georgia surveys include:

“This Web site is very convenient. I work the

nightshift and this was so much easier than

picking up an application.”


APPENDIX

“This Web site is excellent. It provides all the

necessary information I needed in order to

make the decision about applying. It took me

less time applying over the Internet than

writing and mailing in the application.”

“Thank you for making this process so

affordable and easy.”

“This was a very easy way to apply for

PeachCare for Kids. I only have free time at

night to do this sort of thing. Thank you.”

“Thanks for the convenience!”

PennsylvaniaPennsylvania also has a 12 to 15 question

user survey at the end of its online application,and 25 percent of users provide feedback. Ninety-two percent of respondents said the Web site hadexcellent or good “general clarity and ease of use;”six percent rated the site fair, and two percentpoor. Similarly, 96 percent gave the Web site anexcellent or good score on “navigational ease.”

Michigan, Texas and Utah These states have not implemented customerfeedback surveys yet.

Endnotes

1. Kirsten Wysen, State Guide to Online Enrollmentfor Medicaid and SCHIP (Portland, ME: NationalAcademy for State Health Policy, 2003), 3.

2. Available at http://www.ntia.doc.gov/ntiahome/digitaldivide/index.htm, accessed 3/28/03.


http://www.ntia.doc.gov/ntiahome/digitaldivide/index.htm

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