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Designing the Exchange’s IT System

Perhaps the most challenging task in creating the California Health Benefit Exchange is developing the IT infrastructure. The Exchange is faced with never-before-attempted requirements in developing a system that is both complex and user-friendly. The system must be able to interface with other entities, such as county systems, the IRS for income verification and the Department of Homeland security for citizenship verification. It must also be able to direct consumers to various human services programs for which they may be eligible.

The system must be able to display the various options for consumers in a way that is easy to navigate. It must present option of plan, four benefit levels within each plan, each plan’s quality ratings and each plan’s provider network. It must also provide consumers with their estimated premiums based on their income, family size, and geographic location.

Currently, County systems are responsible for determining Medi-Cal eligibility. They do this based on income and asset tests. Currently, parents under 100% of the Federal Poverty Level are eligible for Medi-Cal. In 2014, Medi-Cal will expand to include all individuals under 133% FPL. They will be deemed eligible based on Modified Adjusted Gross Income (MAGI) with no asset tests. Since legislation requires that the Exchange be a single point of entry for both Qualified Health Plans (QHPs) within the Exchange and Medi-Cal enrollment, Exchange could be given the responsibility of determining Medi-Cal eligibility.

Stakeholder workgroups organized by the Exchange Board have begun addressing design options for the Exchange’s IT system in terms of which system would have which responsibilities. They came up with four options.

Option 1: Distributive

Option 1 allows County systems to perform their current duties, including non-MAGI Medi-Cal determinations, in addition to doing MAGI Medi-Cal determinations. Some feel that Option 1 makes the most of current systems and is the easiest way to get to 2014. Stakeholders have argued that County systems have the cultural competency and access to the population of interest. They also have the IT infrastructure in place to do the eligibility determinations.

Option 2: Partially Integrated

Option 2 allows County systems to determine eligibility for non-MAGI Medi-Cal and return the results to the Exchange. The Exchange does determinations for MAGI Medi-Cal and obtains non-MAGI eligibility determinations from County systems.

Option 3: Fully Integrated

Option 3 possibly requires the biggest change. It retires the MRMIB system and restricts County system responsibilities to determining eligibility for human services programs. Option 3 gives the Exchange the responsibility of non-MAGI, MAGI and CHIP eligibility determinations. Stakeholders who are proponents of Option 3 argue that it achieves the overall goal of simplification by allowing the Exchange to do eligibility determinations for MAGI and non-MAGI Medi-Cal and for the Exchange.

Option 4: Integrated Partnership

Option 4 also retires MRMIB and gives CHIP eligibility determination to the Exchange. It then requires the Exchange to do MAGI determinations and to refer potential non-MAGI eligibles to the County. The County is able to determine both non-MAGI and MAGI. Supporters of this model argue that this is a “no wrong door” strategy where individuals can enroll through both the County and the Exchange.

Below is a chart that explains which system would be responsible for which function under each option.

As of now, it seems as though the Exchange Board is leaning towards Option 1. Option 1 would be the least costly and most timely way to create an IT system. These designs will be presented to the selected IT vendor for consideration. The IT vendor has not yet been selected.

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