February  28,  2013    VIA  ELECTRONIC  SUBMISSION      Centers  for  Medicare  &  Medicaid  Services  Department  of  Health  and  Human  Services  P.O.  Box  8016  Baltimore,  MD  21244-­‐8016    Attention:     CMS-­‐10440  

Appendix  A:  List  of  Questions  in  the  Online  Application  to  Support  Eligibility  Determinations  for  Enrollment  through  the  Health  Insurance  Marketplace  and  for  Medicaid  and  the  Children’s  Health  Insurance  Program  Appendix  C:  FA  Paper  Application  Appendix  D:  non-­‐FA  Paper  Application  

 Single,  Streamlined  Application      This  document  provides  very  specific  detailed  suggestions  working  chronologically  through  the  paper  application  and  online  questionnaire.  In  addition,  we  provided  other  comments  regarding  top  priority  issues  that  are  not  addressed  as  thoroughly  in  this  document.    PAPER  APPLICATION  COMMENTS    NON-­‐FINANCIAL  ASSISTANCE  APPLICATION    Our  comments  will  focus  on  the  paper  application  for  financial  help  and  the  online  questionnaire.  To  the  extent  that  the  same  questions  are  asked  or  the  same  language  appears  on  the  non-­‐financial  application,  these  comments  apply.  To  encourage  the  many  individuals  and  families  who  will  be  able  to  get  help  paying  for  insurance,  we  recommend  the  addition  of  language  to  the  non-­‐financial  application.    

Recommendation:  Add  this  line  in  parenthesis  under  the  title  on  the  Application  for  Health  Insurance  –  “If  you  would  like  to  see  if  you  can  get  lower  payments,  do  not  use  this  application.  Find  out  more  or  get  a  different  application  online  at  (insert  link)  or  by  calling  1-­‐888-­‐XXX-­‐XXXX.  

 FINANCIAL  ASSISTANCE  PAPER  APPLICATION  Where  there  is  commonality  between  the  paper  application  and  online  application,  our  specific  comments  apply  to  both.  Our  comments  start  with  the  paper  application  for  financial  assistance.      General  Comments    

Literacy  levels:  We  are  concerned  that  the  application  may  be  difficult  to  complete  for  people  with  low  literacy  skills.  For  example,  research  has  shown  that  many  people  do  not  understand  the  meaning  of  “optional.”  We  recommend  that  HHS  consult  with  health  literacy  experts  who  have  experience  with  low-­‐income  populations.  There  are  two  specific  resources  that  may  be  helpful:    

 “The  Health  Literacy  Style  Manual”  that  was  prepared  for  the  Covering  Kids  and  Families  Initiative  and  created  by  the  Center  for  Health  Literacy  at  Maximus.  This  manual,  which  includes  specific  sections  on  applications  and  translations,  can  be  found  at:  http://www.thesoutherninstitute.org/docs/publications/CKF%20Health%20Literacy%20Style%20Manual%2010-­‐2005.pdf      “Health  Literacy  Educational  Toolkit”  developed  by  the  AMA  Medical  Association  Foundation  and  the  AMA  Medicaid  Association.  This  toolkit  is  available  at:  http://www.ama-­‐assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf.    

 Formatting:  Research  has  shown  that  cross-­‐references,  tables  and  a  lack  of  white  space  make  it  difficult  for  some  people  to  complete  forms.  In  particular,  the  pages  that  are  required  for  each  person  are  too  dense  and  have  too  little  white  space.    Taglines:  We  appreciate  the  inclusion  of  Spanish  taglines.  However,  this  is  insufficient  to  meet  the  needs  of  the  diverse  applicants  who  are  eligible  for  coverage.  We  suggest  adding  taglines  for  the  15  most  prevalent  languages.  If  you  add  a  “Things  to  Know”  page  as  suggested  below,  there  will  be  space  to  include  this  information.    Length  vs.  Clarity  and  Ease  of  Use:  Although  brevity  is  preferred,  it  may  not  always  lend  itself  to  being  simple  and  understandable.  More  information  may  be  needed  to  ensure  that  applicants  understand  the  application  and  what  they  need  to  do.  Experience  in  Medicaid  and  CHIP  demonstrated  that  when  states  favored  shorter  applications,  they  were  often  more  difficult  to  complete  and  comprehend.  We  believe  it  is  more  important  for  the  application  to  build  on  the  best  practices  in  developing  and  perfecting  Medicaid  and  CHIP  applications  over  time  and  not  err  on  the  side  that  brevity  is  best.    What  core  data  elements  constitute  a  valid  application  and  establish  a  Medicaid  filing  date?  It  is  critically  important  that  HHS  establish  the  core  data  elements  that  are  needed  to  constitute  an  Medicaid  application  and  establish  a  filing  date  that  determines  the  effective  date  of  benefits  for  eligible  people.    Cover  Sheet:    Use  this  application  to  see  what  insurance  choices  you  qualify  for:  To  add  clarity  to  this  section,  we  have  the  following  recommendations.  

Recommendation:  Change  bullet  two  to  “A  new  tax  credit  that  can  help  pay  for  private  health  insurance  purchased  from  the  new  Health  Insurance  Marketplace  in  your  state.”  

Recommendation:  If  the  non-­‐financial  application  is  intended  to  see  if  people  qualify  for  exchange  coverage,  the  third  bullet  could  be  eliminated.    Recommendation:  Include  more  examples  for  different  family  sizes.  Minimally  include  the  upper  income  for  a  single  person.  Change  wording  to  –  “Qualifying  for  free  or  low-­‐cost  health  insurance  is  based  on  your  family  size  and  how  much  money  you  make  you  make  (your  income).  A  family  of  four  earning  as  much  as  $94,000  (2013  level)  or  a  single  person  earning  as  much  as  $45,000  may  qualify  for  lower  premiums.  

 Apply  faster  online:  While  this  information  should  be  on  the  page,  if  space  becomes  an  issue,  it  could  be  a  smaller  single  line  at  the  bottom  of  the  application.    Get  help  with  this  application:  In  order  for  people  to  know  they  can  get  help  rather  than  complete  the  application  on  their  own,  we  recommend  moving  this  section  higher  up  on  the  cover  page.  

Recommendation:  Move  the  “Get  Help”  section  up  to  follow  “Apply  faster  online.”  Recommendation:  Add  a  bullet  to  this  section;  “If  you  do  not  speak  English,  we  will  get  an  interpreter  to  help  you.  There  is  no  cost  to  you  to  use  an  interpreter.  Please  call  1-­‐888-­‐XXX-­‐XXXX.”  

 What  you  may  need  to  apply:  This  language  doesn’t  fully  convey  that  gathering  the  suggested  information  will  make  it  easier  to  complete  the  application  or  that  not  all  of  the  information  is  required  to  complete  the  application.  

Recommendation:  Change  to  “This  application  may  be  easier  to  complete  if  you  gather  some  information  in  advance  if  you  have  it.  You  can  still  submit  an  application  even  if  you  do  not  have  some  of  this  information.”  Recommendation:  The  first  bullet  regarding  Social  Security  numbers  (SSN)  specifies  that  document  numbers  are  needed  for  legal  immigrants  who  need  insurance.  It  doesn’t  say  that  SSNs  are  needed  only  for  those  applying  for  coverage.    

 Why  do  we  ask  for  so  much  information:  This  information  is  not  sufficient  to  reassure  applicants  about  privacy,  why  information  is  needed  and  how  it  is  used.  Please  see  our  recommendation  below  to  add  a  “Things  to  Know”  page  that  follows  the  cover  sheet.  If  more  thorough  descriptions  are  not  added  in  a  “Things  to  Know”  page,  we  recommend  the  following  changes  to  the  this  section:  

Recommendation:  Add  “secure”  to  the  second  sentence  as  follows:  “We’ll  keep  all  the  information  you  private  and  secure,  as  required  by  law.”  Recommendation:  Add  this  sentence  –  “Information  on  this  application  is  only  used  to  determine  eligibility  for  health  insurance.”  

 What  happens  next:  It  is  most  important  that  this  information  appear  at  the  end  of  the  application  after  instructions  for  mailing.  If  space  becomes  an  issue  on  this  page  you  can  abbreviate  this  section  as  follows:  

Recommendation:  “What  happens  after  you  complete  the  application…At  the  end  of  the  application,  we  tell  you  where  to  send  the  application  and  what  happens  next.  

You  do  not  have  all  the  information  we  ask  in  order  to  sign  and  send  in  the  application.  

 Add  “Things  to  Know”  page:  Information  provided  at  the  beginning  of  the  application  is  critical  to  ensuring  that  applicants  feel  secure  in  submitting  personal  and  confidential  information.  This  is  particularly  true  for  mixed  immigrant  families  and  we  address  their  unique  needs  in  separate  comments.  We  recommend  the  inclusion  of  a  “Things  to  Know”  page  after  the  coverage  page  that  includes  the  following  information:    

We  keep  all  information  you  tell  us  private  and  secure.  We  will  keep  all  the  information  you  provide  private  and  secure  as  required  by  law.  We  will  use  it  only  to  check  if  you  are  eligible  for  health  insurance.      You  can  tell  us  if  you  do  not  want  us  to  check  to  see  if  everyone  in  your  family  or  living  with  you  can  get  health  insurance.  You  may  file  applications  for  families  and  households  that  include  some  members  applying  for  health  coverage  and  others  who  are  not.  You  do  not  have  to  provide  a  Social  Security  number  (SSN)  or  immigration  status  for  people  in  your  family  who  are  not  seeking  coverage.  We  will  not  delay  or  deny  health  coverage  because  there  are  family  members  who  are  not  seeking  coverage.  For  those  who  do  not  apply,  we  can  give  you  information  about  other  ways  to  get  health  care.      You  cannot  be  discriminated  against.  Under  federal  law,  discrimination  is  not  permitted  on  the  basis  of  race,  color,  national  origin  (language  or  limited  English  proficiency),  sex,  or  disability.  To  file  a  complaint  of  discrimination,  go  to  www.hhs.gov/ocr/office/file.    

 Families  that  include  immigrants  are  welcome  to  apply  for  help  with  health  insurance  costs.      If  you  do  not  speak  English,  we  will  get  an  interpreter  to  help  you  at  no  cost  to  you.  Please  call  (XXX)  XXX-­‐XXXX.  (In  top  15  languages)    Applying  for  health  insurance  or  getting  help  with  health  insurance  costs  will  not  make  you  a  “public  charge”*  and  will  not  affect  your  immigration  status  or  chances  of  becoming  a  lawful  permanent  resident  (getting  a  “green  card”)  on  that  basis.  Applying  for  health  benefits  won’t  prevent  you  from  becoming  a  citizen,  as  long  as  you  tell  the  truth  on  the  application.    

 Step  1  –  Tell  us  about  yourself:    The  instructions  below  “Step  1”  are  too  vague  to  allow  an  individual  to  understand  the  purpose  of  this  step.  We  suggest  CMS  add  additional  language  explaining  that  this  information  is  requested  of  the  person  who  should  be  contacted  about  the  application.    

Recommendation:  Amend  the  wording  to:  “Tell  us  about  yourself.  (We  need  one  adult  member  in  the  family  to  be  the  contact  person  for  your  application.  We  will  

contact  this  person  if  we  have  any  questions  and  to  provide  information  about  your  eligibility.  If  this  is  not  you,  please  tell  us  who  should  be  the  contact  person.)”  

 Step  2  –  Leading  instructions:    This  section  should  provide  more  background  and  context.  Applicants  need  to  understand  why  they  are  being  asked  detailed  questions  regarding  their  income,  family  size,  and  living  arrangements  that  may  seem  intrusive  and,  at  times,  repetitive.  Also,  applicants  are  likely  seeking  the  best  coverage,  not  the  most  coverage  possible  as  the  text  currently  includes.  The  best  coverage  may  include  considerations  related  to  cost-­‐sharing  which  most  coverage  may  not.    

Recommendation:  We  suggest  changing  the  language  as  follows:  “You  and  your  family  members  may  qualify  for  low  or  no  cost  health  insurance  programs  or  for  lower  payments  to  buy  health  insurance.  The  amount  of  assistance  or  type  of  health  insurance  depends  on  your  family  size,  income,  and  living  arrangements  in  your  household.  By  providing  information  in  the  following  sections,  we  can  make  sure  everyone  applying  for  health  insurance  coverage  gets  the  best  coverage  possible.”  

 Who  needs  to  be  included  on  this  application:    This  bulleted  list  should  start  with  “You.”  Additionally  the  language  here  is  not  completely  consistent  to  the  instructions  that  follow  on  the  individual  person  pages  (Step  2  Persons  1-­‐6).    The  bulleted  list  says  to  include  your  spouse,  partner  who  lives  with  you  (but  only  if  you  have  children  together  who  need  health  insurance)  and  anyone  you  include  on  your  federal  income  tax  return.  The  Step  2  doesn’t  qualify  whether  to  include  your  partner.  Additionally,  if  you  don’t  file  a  tax  return,  remember  to  still  add  family  members  who  live  with  you.  It’s  not  clear  who  “family  members”  are.      It’s  also  confusing  (and  contradictory  to  the  statement  about  everyone  getting  the  most  (best)  coverage  possible)  why  an  applicant  needs  to  list  anyone  included  on  their  tax  return  but  that  person  will  have  to  file  their  own  application.  More  explanatory  text  is  needed.  

Recommendation:  Replace  the  statement  about  a  separate  application  with  “While  you  must  include  anyone  on  your  tax  return  in  order  for  us  to  know  the  size  of  your  household,  any  person  on  your  tax  return  that  is  not  your  spouse,  partner  with  whom  you  have  a  child  or  your  child  will  need  to  file  their  own  application  if  they  want  insurance.”  

 Step  2  Pages  for  Providing  Information  for  Persons  1-­‐6.      Child  Specific  Pages  –  For  children  who  do  not  file  taxes,  less  information  is  required.  If  space  is  an  issue,  consider  drafting  child  only  pages  that  eliminate  unnecessary  information.    White  Space  and  Crowding  –  There  is  insufficient  white  space  on  these  pages,  and  additional  information  (specifically  language  preferences  for  everyone)  needs  to  be  added.    Use  of  Word  “Optional”  –  The  Health  Literacy  Style  Manual  referenced  earlier  specifically  notes  that  many  people  do  not  understand  the  meaning  of  this  work.    

Recommendation:    Replace  optional  with  “not  required.”    Redundant  Request  for  Social  Security  Number  –  The  second  SSN  request  can  be  eliminated  by  amending  the  explanatory  text  associated  with  the  first  request.  The  recommended  language  below  could  be  trimmed  if  it  is  fully  explained  on  the  “Things  to  Know”  page.  However,  repetition  can  be  useful  when  communicating  key  messages  to  mixed  status  families.  

Recommendation:  Move  the  SSN  field  to  align  with  the  explanatory  text  so  they  are  clearly  associated.  Remove  the  OPTIONAL  next  to  the  SSN  field.  Amend  the  explanatory  language  to  read:  “You  only  need  to  provide  Social  Security  Numbers  (SSNs)  for  family  members  applying  for  health  insurance,  if  they  have  one.  An  SSN  is  not  required  for  people  listed  on  the  application  but  not  applying  for  insurance.  We  will  not  delay  or  deny  health  coverage  because  there  are  family  members  who  are  not  seeking  coverage.  SSNs  are  used  to  check  how  much  money  you  make  (your  income)  and  citizenship  to  see  who  is  eligible  for  help  with  insurance.  However,  providing  the  SSN  for  all  family  members  who  earn  income  can  speed  up  the  application  process.  If  someone  who  is  applying  for  coverage  does  not  have  an  SSN,  you  can  get  help  by…..  

 Is  Person  X  applying  for  health  insurance  –  We  suggest  more  language  to  encourage  people  who  have  insurance  to  apply.    

Recommendation:  Amend  the  text  in  parenthesis  to:  “You  can  apply  if  you  have  current  private  insurance.  Even  people  who  have  insurance  may  be  able  to  get  better  coverage  or  lower  costs.”  

 Disability  –  There  is  insufficient  detail  in  the  question  about  daily  living  activities  to  adequately  screen  for  people  who  may  qualify  for  other  categories  of  Medicaid  but  do  not  have  a  confirmed  disability.  One  suggestion  would  be  to  insert  a  new  step  between  the  current  Steps  2  and  3  or  3  and  4.  This  step  could  better  articulate  the  kinds  of  questions  that  would  lead  to  better  screening  and  give  applicants  information  about  the  possibility  of  getting  better  benefits  by  applying  for  non-­‐MAGI  Medicaid.  Such  questions  might  include  those  used  by  the  American  Community  Survey  to  collect  data  on  disability  status,  as  well  as  other  child-­‐specific  questions  noted  below.    

Recommendation:  Retain  the  question  on  whether  the  person  has  a  disability.  Delete  the  question  about  daily  activities  and  add  a  step  for  disabilities  that  includes  these  questions:  You  or  a  family  member  may  be  eligible  for  more  benefits  and  lower  costs  if  you  answer  yes  to  any  of  the  questions  below.      

1. Are  you  or  is  anyone  on  this  application  deaf,  or  have  serious  difficulty  hearing?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

2. Do  you  or  does  anyone  on  this  application  have  serious  difficulty  seeing  even  when  wearing  glasses?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?  

 

3. Because  of  a  physical,  mental,  or  emotional  condition,  do  you  or  does  anyone  on  this  application  have  serious  difficulty  concentrating,  remembering,  or  making  decisions?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

4. Do  you  or  does  anyone  on  this  application  have  serious  difficulty  walking  or  climbing  stairs?  Yes  ____    No  ____  If  yes,  who  _____________________________________________________?      

5. Do  you  or  does  anyone  on  this  application  else  have  difficulty  dressing  or  bathing?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

6. Because  of  a  physical,  mental,  or  emotional  condition,  do  you  or  does  anyone  on  this  application  have  difficulty  doing  errands  alone  such  as  visiting  a  doctor's  office  or  shopping?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

7. Is  any  child  on  this  application  limited  or  prevented  in  any  way  in  his  or  her  ability  to  do  the  things  most  children  of  the  same  age  can  do?  Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

8. Does  this  child  need  or  use  more  medical  care,  mental  health  or  educational  services  than  is  usual  for  most  children  of  the  same  age?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

9. Do  any  of  your  children  have  a  medical  condition  that  left  untreated  would  result  in  the  death  or  serious  physical  injury  of  the  child?    

10. Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

The  disability  page  should  include  additional  information  on  how  to  get  more  information  or  apply  for  non-­‐MAGI  Medicaid.  

 Foster  Care  Question  –  Explain  why  this  information  is  needed.  

Recommendation:  Add  this  information  to  this  question.  “If  you  or  someone  else  applying  for  health  insurance  were  once  in  the  foster  care  system,  that  person  may  be  eligible  for  more  benefits  at  lower  costs.  Help  us  decide  if  you  are  eligible  by  answering  the  following  question.”  

 Race  and  Ethnicity  –The  ACA  requires  collection  and  reporting  of  these  data,  including  primary  language,  for  applicants,  recipients  or  “participants”  (emphasis  added).  The  household  contact  is  a  participant.  

Recommendation:  Move  the  questions  on  race  and  ethnicity  to  above  whether  the  person  is  applying  for  coverage.    

 Language  –  As  noted  above,  the  ACA  requires  collecting  and  reporting  primary  language.    

Recommendation:  Preferences  for  written  and  spoken  language  should  be  asked  for  all  applicants.  

 Person  1  vs.  Persons  2-­‐6    –  The  starting  instructions  on  page  3  are  unclear.  

Recommendation:    Amend  the  language  on  Person  1  to  read  “Complete  Step  2  for  yourself.  On  subsequent  pages,  amend  the  language  to  read  “Complete  Step  2  to  for  your  spouse/partner  (if  you  and  your  partner  have  a  child),  each  of  your  children  who  live  with  you,  other  family  members  who  live  you  and  anyone  else  you  include  on  your  federal  tax  return.  

 Domestic  Partnerships:    It  is  important  to  provide  additional  information  on  when  domestic  partners  can  qualify  for  help  with  health  insurance.    Income  –  Current  Jobs:  Many  people  work  jobs  that  are  seasonal  or  where  their  work  is  on  call.    

Recommendation:    Add  seasonal  and  varies  to  the  list  of  frequency  with  space  for  an  explanation.    

 Income  –  Changes  in  Past  Six  Months:  This  section  seems  connected  to  the  current  job  2.    

Recommendation:    Make  the  separating  line  wider  and  gray  or  insert  additional  space  to  separate.  

 Income  –  Other  Income:  Clarify  that  veteran’s  payments  means  veteran’s  benefits  not  veteran’s  retirement.    Income  –  Pretax  Contributions  and  Deductions:    MAGI-­‐based  income  excludes  contributions  for  health  insurance  premiums  paid,  child  care,  transportation  benefits  and  certain  retirement  plans.  Additionally,  qualifying  deductions  for  alimony,  student  loan  interest  and  other  items  should  be  included.  The  application  does  not  gather  this  information  and  will  thus  overstate  income  significantly  in  some  cases,  which  will  result  in  improperly  screening  for  Medicaid  eligibility  or  understating  the  level  of  APTCs  and  cost-­‐sharing  reductions    

Recommendation:    Add  questions  regarding  pre-­‐tax  contributions  and  deductions.    Income  –  Yearly  Income:    This  section  needs  a  definition  for  what  should  be  included  in  yearly  income.    

Recommendation:    Asking  someone  to  project  annual  income  is  extremely  difficult.  In  the  online  environment,  we  recommend  the  use  of  a  worksheet  that  helps  someone  calculate  his/her  yearly  income  less  pre-­‐tax  deductions.  For  the  paper  application,  we  are  concerned  about  the  accuracy  of  what  is  reported  and  how  it  might  be  used.      

 Step  3  –  Insurance  from  Jobs    Employee  SSN  –  It  is  redundant  to  ask  for  an  SSN  for  a  third  time  on  the  application.  

Recommendation:    Delete  the  field  for  SSN.    

 Employer  EIN  –  The  asterisk  explanation  requires  a  cross-­‐reference  and  is  hard  to  find.  Provide  this  help  text  in  the  field  or  suggest  the  applicant  check  their  W-­‐2.  

Recommendation:    Insert  this  statement  in  the  field  with  the  request  for  the  EIN.  “You  can  ask  your  employer  for  this  information  (see  page  XX)  or  find  it  on  the  W-­‐2  year  end  wages  form  from  your  employer.”  

 Minimum  Value  Standard  Coverage  Questions:    We  are  very  concerned  about  asking  individuals  questions  that  few  people  can  answer.  Trying  to  get  at  whether  the  employee  is  “offered”  or  “eligible  for”  enrollment  is  just  too  complicated  to  get  valid  answers.  We  recommend  that  the  applicant  not  be  requested  to  provide  this  information.  Preferably,  the  only  question  should  be  “does  your  employer  offer  health  coverage?”  If  yes,  the  exchange  should  contact  the  employer  to  obtain  necessary  information.      Name  of  Lowest  Cost  Self-­‐Only  Health  Plan:  Most,  if  not  all,  people  will  not  understand  what  this  means.  Self-­‐only  should  be  clearly  articulated  as  coverage  for  the  employee  only.  Additionally,  it  should  be  clarified  what  information  is  being  request  by  “name  of  the  health  plan.”  Is  it  the  insurance  carrier  name?  Is  it  whether  the  plan  is  a  PPO  or  HMO?  Is  it  the  product  name  such  as  Carefirst?  

Recommendation:    If  this  section  is  not  deleted,  rephrasing  of  this  question  is  needed.  We  recommend  that  extensive  consumer  testing  be  conducted  to  craft  the  best  wording  of  these  questions  to  ensure  an  accurate  outcome  of  eligibility.  

 Is  Employer  Coverage  Affordable:    It  is  not  clear  why  this  question  is  needed  or  how  it  will  be  used.  

Recommendation:  Eliminate  this  question.    Will  Employer  Coverage  Be  Affordable  Next  Year:  It  is  not  clear  why  this  question  is  needed  or  how  it  will  be  used.  

Recommendation:  Eliminate  this  question.    Other  Health  Coverage:    We  offer  several  recommendations  for  this  section.  However,  we  are  particularly  concerned  about  people  who  are  enrolled  in  COBRA  coverage  and  paying  more  than  100%  of  the  cost  of  coverage,  which  is  often  considered  unaffordable.  While  they  cannot  get  APTCs  while  enrolled  in  COBRA,  they  can  drop  COBRA  and  enroll  in  a  QHP  with  financial  assistance  at  open  enrollment.  Additional  information  should  be  provided  to  inform  applicants  that  they  may  be  able  to  get  better  and  lower  cost  coverage  if  they  do  so.  Eligibility  should  be  processed  for  those  with  COBRA  coverage  and  pended  until  disenrollment  from  COBRA  is  verified.  

Recommendation:  Substitute  “Coverage”  for  “Insurance”  in  this  section.  Recommendation:  Clarify  that  this  section  pertains  to  people  “enrolled”  in  other  coverage  and  not  just  eligible  for.    Recommendation:  Add  Student  Health  Insurance  to  the  list.    Recommendation:  Ask  when  the  COBRA  coverage  ends  and  add  this  question:  “Would  you  terminate  your  COBRA  coverage  if  you  were  found  eligible  for  another  health  program?”  

 Step  5  –  Review  and  Sign    Reporting  Changes  (Bullet  2):    It  would  be  helpful  to  be  more  specific  about  what  changes  people  are  required  to  report.  Also  since  this  application  is  used  for  Medicaid  as  well,  it  is  not  just  the  Exchange  that  needs  to  be  notified.  Reported  income  changes  in  the  Exchange  are  treated  differently  than  in  Medicaid  and  this  section  does  not  address  those  differences.  It  may  be  that  this  information  is  best  dealt  with  in  eligibility  notices,  or  at  least  reiterated  and  specific  to  the  program  of  eligibility.  

Recommendation:    Rephrase  the  second  sentence  in  the  second  bullet  (or  include  it  as  a  separate  bullet)  as  follows  “I  know  that  I  must  tell  the  Health  Insurance  Marketplace  or  Medicaid  if  I  move,  have  a  change  in  income  or  someone  is  added  to  or  leaves  my  household.  

 Renewal  of  Coverage:    Ideally,  renewal  information  is  addressed  in  the  notice  of  eligibility  because  at  the  time  of  application,  it  is  not  clear  which  program  rules  will  apply  at  renewal.    

Recommendation:    Delete  instructions  about  renewal  and  include  appropriate  information  regarding  renewal  and  reporting  charges  on  the  notice  of  eligibility.    

Medicaid  Eligibility/Medical  Support:  Recommendation:  Rephrase  the  second  sentence  as  follows:  “If  I  think  that  cooperating  to  collect  medical  support  will  harm  me  or  my  children,  I  can  tell  Medicaid  when  they  contact  me  and  I  will  not  have  to  cooperate.”  

 Your  Right  to  Appeal:    We  suggest  testing  whether  “action”  is  the  right  word  to  be  used  here.  Decision  could  be  a  better  alternative.    Two  Signature  Lines:    It  is  not  clear  who  should  sign  (if  anyone)  on  the  second  signature  line.    What  Happens  Next:    Consider  moving  to  the  next  page  below  where  to  mail,  fax  or  e-­‐mail  the  application.    Authorized  Representative:    We  have  the  following  recommendations  for  this  section:  

Recommendation:  Add  relative  to  the  examples  of  who  might  serve  as  an  authorized  representation.    Recommendation:  Ask  if  any  renewal  notices  should  also  be  sent  to  the  authorized  representative.  Even  if  selecting,  notices  should  also  be  sent  to  the  enrollee.  Recommendation:  Include  language  that  tells  the  applicant  that  they  can  change  or  remove  their  authorized  representative  at  any  time  and  how  they  would  do  so.    

 Step  6    Ways  to  Submit  Application:    Applications  can  be  mailed  or  submitted  via  common  electronic  transmission  including  fax  and  e-­‐mail.  Additionally,  some  people  will  prefer  to  drop  off  applications  personally.  

Recommendation:    Include  instructions  for  faxing  or  e-­‐mailing  a  scanned  version  of  the  application.  Provide  information  on  where  an  applicant  can  drop  off  the  application  in  person  (either  the  exchange  office  or  at  a  navigator  or  certified  application  counselor  site).  

 Instructions  for  Eligible  Immigration  Status:    Need  to  clarify  that  this  means  “immigration  status  that  is  eligible  to  enroll  in  health  insurance.”  It  is  also  important  to  repeat  reassuring  language  that  immigration  status  is  only  used  to  see  if  someone  can  get  help  with  health  insurance,  and  not  for  enforcement  purposes.    Employer  Coverage  Form:  The  application  should  provide  for  the  applicant  to  attach  a  form  developed  by  their  employer  that  includes  the  needed  information.  Employers  may  choose  to  post  similar  information  their  website  or  provide  directly  to  employees  at  open  enrollment,  and  thus  requiring  that  they  fill  out  the  application  form  is  duplicate  and  unnecessary.      ONLINE  QUESTIONNAIRE    General  Comments    We  commend  the  effort  that  has  gone  into  to  simplifying  and  streamlining  the  online  and  paper  applications.  In  the  online  environment,  the  use  of  dynamic  questioning  and  help  text  or  pop-­‐up/hoover  alerts  can  be  extremely  helpful  in  making  the  process  as  smooth  and  easy  as  possible.  However,  it  is  difficult  to  provide  well-­‐rounded  feedback  without  being  able  to  “test  drive”  the  application  or  review  the  planned  “help  or  explanatory”  text  language.  We  ask  that  there  be  future  opportunities  to  weigh  in  on  the  ease  of  use  of  a  working  version  of  the  application,  as  well  as  review  proposed  wording  of  help  text  and  alerts.    Literacy  levels:  We  are  concerned  that  the  application  may  be  difficult  to  complete  for  people  with  low  literacy  skills.  For  example,  research  has  shown  that  many  people  do  not  understand  the  meaning  of  “optional.”  We  recommend  that  HHS  consult  with  health  literacy  experts  that  have  experience  with  low-­‐income  populations.      Taglines:  We  appreciate  the  inclusion  of  Spanish  taglines.  However,  this  is  insufficient  to  meet  the  needs  of  the  diverse  applicants  who  are  eligible  for  coverage.  We  suggest  adding  taglines  for  the  15  most  prevalent  languages.  Additionally,  the  online  application  should  be  translated  in  to  these  languages.    

Recommendation:    Add  language:  “If  you  do  not  speak  English,  we  will  get  an  interpreter  to  help  you  at  no  cost  to  you.  Please  call  1-­‐888-­‐XXX-­‐XXXX.      

 Landing  Page:  The  home  page  of  the  health  portal  that  houses  the  online  application  should  be  inviting  and  welcoming.  It  should  provide  additional  information  about  the  insurance  affordability  programs,  as  well  as  encourage  language  for  individuals  and  families  to  apply  for  financial  assistance  and  reassuring  language  for  immigrants  and  mixed  immigration  status  families.  Before  someone  starts  to  enter  data,  it  should  provide  privacy  

notices  and  clear  information  about  how  information  will  be  used  (i.e.  to  check  income  and  citizenship)  and  how  it  will  not  be  used  (for  enforcement  purposes).    Suggestions  include:      

You  may  file  applications  for  families  that  include  some  members  applying  for  health  coverage  and  others  who  are  not.  You  do  not  have  to  provide  a  Social  Security  number  (SSN)  or  citizenship  or  immigration  status  for  those  in  your  family  who  are  not  seeking  coverage.  We  will  not  delay  or  deny  health  coverage  because  there  are  family  members  who  are  not  seeking  coverage.      We  will  keep  all  the  information  you  provide  private,  confidential  and  secure  as  required  by  law.  We  will  use  it  only  to  check  if  you  or  family  members  who  are  applying  are  eligible  for  health  insurance.      Under  federal  law,  discrimination  is  not  permitted  on  the  basis  of  race,  color,  national  origin  (language  or  limited  English  proficiency),  sex,  or  disability.  To  file  a  complaint  of  discrimination,  go  to  www.hhs.gov/ocr/office/file.    

 Applying  for  health  insurance  or  getting  help  with  health  insurance  costs  will  not  make  you  a  “public  charge”  and  will  not  affect  your  immigration  status  or  chances  of  becoming  a  lawful  permanent  resident  (getting  a  “green  card”)  on  that  basis.  Applying  for  health  benefits  won’t  prevent  you  from  becoming  a  citizen,  as  long  as  you  tell  the  truth  on  the  application.    

 Use  of  Word  Optional:  Many  people  will  not  understand  what  “optional”  means.  The  use  of  this  word  and  alternatives  such  as  “not  required”  should  be  tested  with  diverse  groups  of  likely  eligible  people.    

Recommendation:  Replace  optional  with  “not  required.”    Use  of  Confusing,  Interchangeable  Words:  In  a  number  of  places  household  and  family  and  exchange  and  marketplace  are  used  interchangeably.  The  latter  is  easier  to  address  given  that  the  preferred  reference  to  the  exchange  is  Health  Insurance  Marketplace.  The  former  is  trickier  because  the  words  household  and  family  may  be  used  in  different  contexts.    

Recommendation:    Replace  all  uses  of  exchange  with  Health  Insurance  Marketplace  Recommendation:  Provide  pop-­‐up  explanations  of  what  is  needed  or  meant  in  each  specific  use  of  family  and  household.  

 Use  of  Alerts  (pop-­‐up  explanations  or  warnings)  and  Help  Text:    We  are  pleased  to  know  that  technology  tools  will  be  used  to  facilitate  the  application  process.  In  our  comments,  we  refer  to  alerts  as  tools  that  are  enabled  by  “hovering”  over  text  or  by  an  “automatic  pop-­‐ups”  when  someone  clicks  on  a  data  entry  field.  On  the  other  hand,  “help  text”  is  something  (i.e.  an  icon  or  ?)  the  user  clicks  for  further  information.  The  primary  delineation  is  that  alerts/pop-­‐ups  occur  when  the  user  is  about  to  enter  information  into  a  field.  Help  text  

icons  or  question  marks  are  clicked  when  a  user  wants  additional  information  at  certain  point  in  the  application.        Given  that  alerts  and  help  text  are  critically  important  to  successfully  self-­‐navigation  of  the  application,  we  request  an  opportunity  to  review  proposed  text  and  messages  and  provide  feedback.  Additionally,  it  is  imperative  that  alerts  and  help  text  language  be  tested  with  diverse  groups  of  likely  eligible  people.    General  Comments  &  Concerns  

 Screen  first  for  Medicaid  –  We  would  expect  that  the  single,  streamlined  application  for  all  insurance  affordability  programs  would  treat  the  programs  equally,  yet  the  application  is  generally  seems  more  focused  on  collecting  information  to  determine  APTC  eligibility  than  Medicaid.  Since  individuals  eligible  for  Medicaid  or  CHIP  are  not  eligible  for  APTCs,  it  is  important  to  first  screen  for  Medicaid  or  CHIP  eligibility.  However,  the  sequencing  of  this  application  puts  much  emphasis  on  collecting  information  regarding  tax-­‐filers  and  eligibility  for  APTCs  to  construct  both  the  MAGI  and  APTC  household  sizes  simultaneously.  We  would  recommend  that  HHS  consider  an  alternative  that  builds  a  straightforward  assessment  of  Medicaid  eligibility  without  unnecessary  questions  related  to  tax  filings  and  future  income.  Further  recommendations  are  detailed  below.    Insert  Privacy  Notification  Prior  to  Account  Set-­‐Up:  Before  data  is  entered  or  an  account  set-­‐up,  the  online  application  should  provide  detailed  information  about  the  privacy  of  data  and  how  information  will  be  used.      

Recommendation:    Before  asking  someone  to  set  up  an  account,  display  detailed  data  about  why  information  is  needed  and  how  it  will  be  used  in  an  active  voice.  Provide  reassuring  messages  for  immigrant  and  mixed  status  families.  

 As  currently  phrased,  the  privacy  statement  attests  that  the  household  contact  has  consent  from  all  people  listed  on  the  application  allow  their  information  to  be  retrieved  from  data  sources.    

Recommendation:    It  is  important  to  be  specific  about  what  information  will  be  retrieved,  from  what  data  sources  and  how  it  will  be  used.  

 Account  set-­‐up  and  Authentication:    We  appreciate  that  recommended  NIST  800-­‐530  standards  for  security  of  government  information  technology  systems  protect  access  to  information  housed  in  federal  databases.  Conduct  authentication  only  after  the  applicant  affirms  that  they  wish  to  apply  for  themselves  and/or  other  family  members.  

Recommendation:  Display  an  alert  that  when  the  person  clicks  to  get  started,  what  is  going  on  behind  the  scenes  to  authenticate  who  they  are.  

 We  are  concerned  that  potentially  eligible  applicants  who  are  unable  to  provide  an  SSN  that  is  required  for  account  set-­‐up  will  be  locked  out  of  an  electronic  option  for  applying.  

Recommendation:    Provide  an  electronic  path  for  individuals  and  families  to  complete  and  submit  an  electronic  application  that  does  not  require  an  account  set-­‐up  but  allows  the  applicant  to  start,  save  and  return  to  an  application.  We  recognize  

that  in  these  circumstances,  applicants  will  not  be  able  to  take  advantage  of  real-­‐time  verification  of  eligibility.  However,  we  are  concerned  that  locking  these  individuals  and  families  out  of  the  online  application  process  will  be  administratively  inefficient  and  result  in  eligible  people  slipping  through  the  cracks  because  they  misinterpret  the  inability  to  set  up  an  account  as  ineligibility.  

 Additionally,  we  believe  that  it  will  be  very  confusing  to  set  up  an  account  that  will  be  used  going  forward  in  the  exchange  but  not  in  Medicaid.  Additional  thought  needs  to  go  into  communicating  with  consumers  what  the  account  is  and  how  it  be  used.  If  all  members  of  the  family  are  found  Medicaid  eligible,  consumers  should  have  the  option  to  the  delete  the  account  if  they  have  to  go  through  a  process  of  setting  up  a  different  account  in  Medicaid.  If  some  members  are  eligible  for  Medicaid  and  some  for  the  exchange,  consumers  will  needed  to  be  educated  about  why  they  will  need  to  have  two  online  accounts.    Getting  Started    Contact  Information:    Clarify  that  the  household  contact  should  be  an  adult  member  of  the  family  and  not  a  friend  or  relative  who  is  assisting  with  the  application.      

Recommendation:  Provide  help  text  when  someone  starts  to  enter  the  household  contact  information  such  as:  “We  need  one  adult  member  in  the  family  to  be  the  contact  person  for  your  application.  We  will  contact  this  person  if  we  have  any  questions  and  to  provide  information  about  your  eligibility.  If  this  is  not  you,  please  tell  us  who  should  be  the  contact  person.  We  will  ask  you  later  if  you  would  also  given  a  trusted  friend,  relative  or  partner  permission  to  talk  to  us  about  this  application  with  us.  However,  you  should  not  enter  that  person’s  information  here.”    

 No  Home  Address  –  We  appreciate  that  the  application  recognizes  that  an  applicant  might  be  homeless,  however  we  believe  further  guidance  needs  to  be  provided  when  requiring  a  mailing  address.    

Recommendation:  Please  provide  the  address  of  a  trusted  friend  or  relative,  or  organization  (such  as  a  homeless  shelter  or  general  delivery  post-­‐office)  that  agrees  to  receive  mail  on  your  behalf.    

 Preferred  Language  –  We  are  pleased  that  the  application  asks  for  both  preferred  spoken  and  written  language.  It  would  be  helpful  to  explain  why  this  is  being  asked,  how  it  will  be  used  and  why  is  helpful  to  collect  this  information.  

Recommendation:  Provide  help  text  at  the  preferred  language  fields  such  as:  “We  ask  for  your  language  so  we  can  help  you  apply  for  coverage.  This  information  is  confidential  and  will  not  be  used  to  determine  if  you  get  health  insurance.  You  do  not  have  to  provide  your  language  to  complete  this  application.    

 Method  of  Contact  –  It  is  not  clear  whether  this  question  establishes  the  preferred  method  of  contact  just  for  follow-­‐up  on  the  application  or  carries  forward  on  an  ongoing  basis.  If  this  is  how  the  applicant  will  receive  communications  and  notices  on  an  on-­‐going  basis,  it  is  important  to  state  this  clearly.  However,  there  will  confusion  for  families  who  are  found  eligible  for  Medicaid  and  will  not  be  using  the  same  account  for  managing  their  insurance  

going  forward.  Recommendation:    Clarify  if  this  is  how  only  follow-­‐up  communication  on  the  application  will  be  received  or  whether  it  sets  up  preferences  that  carries  over  to  a  permanent  exchange  account  where  enrollees  manage  their  enrollment  and  other  personal  information.  

 Text  charges  –  When  someone  selects  receipt  of  notices  via  text  message,  make  sure  they  are  alerted  that  receiving  text  messages  could  be  subject  to  phone  charges.      Changing  Preferences  –  Be  clear  that  these  preferences  can  be  changed  at  any  time  and  how  they  can  be  changed.    Authorized  Representative    We  have  the  following  recommendations  for  this  section:  

Recommendation:  Add  relative  to  the  examples  of  who  might  serve  as  an  authorized  representation.    Recommendation:  Ask  if  any  renewal  notices  should  also  be  sent  to  the  authorized  representative.  Even  if  selecting,  notices  should  also  be  sent  to  the  enrollee.  Recommendation:  Include  language  that  tells  the  applicant  that  they  can  change  or  remove  their  authorized  representative  at  any  time  and  how  they  would  do  so.    Recommendation:    Embed  an  alert  that  provides  additional  information  when  and  what  documents  may  be  needed  to  establish  the  legal  reason  for  authorizing  a  representative.  Also  include  a  dropdown  list  of  acceptable  documents  that  can  be  submitted  as  proof.    

 Help  Paying  for  Coverage    Who  needs  health  insurance:  The  first  question  asks,  who  are  you  apply  for  health  insurance  and  health  benefits  for.  We  think  the  use  of  these  two  terms  is  confusing.  

Recommendation:  Change  the  first  question  to  “Tell  us  who  wants  to  get  health  insurance.”  

 Do  you  want  to  find  out  if  you/your  family  can  get  help  paying  for  health  insurance:  It  is  critically  important  to  explain  what  kind  of  help  is  available.  As  noted  in  comments  on  the  paper  application,  give  several  family  examples,  ranging  from  a  single  person  to  a  family  of  three  or  four  is  minimally  needed  to  demonstrate  the  higher  levels  of  income  that  can  still  qualify  for  lower  premiums  and  potentially  out-­‐of-­‐pocket  costs.    Income  Screener      We  commend  the  inclusion  of  a  screener  that  may  help  someone  who  has  made  a  pre-­‐determination  that  they  are  not  eligible  to  look  again.  If  you  provide  realistic  examples  as  suggestion  above,  hopefully  fewer  people  will  hastily  select  “no.”  It  will  also  be  important  to  inform  people  at  various  key  times  they  can  go  back  apply  for  financial  assistance  (this  will  be  particularly  important  when  they  are  looking  at  plans  and  prices.)  

 We  are  pleased  to  know  that  screening  will  include  a  buffer  to  account  for  pre-­‐tax  deductions.  At  400  percent  of  the  poverty  level,  families  could  have  significant  childcare,  retirement  or  other  deductions  that  reduce  their  gross  income  for  eligibility  purposes.      We  suggest  additional  wording  at  B.2.b  as  follows:  

Recommendation:  Insert  “be  denied  or”  before  ay  higher  costs  for  pre-­‐existing  conditions.  

 Tell  Us  How  Many  People  are  Applying    This  section  is  only  displayed  if  the  household  contact  indicates  there  are  other  family  members  who  want  insurance.  It  is  not  clear  why  the  household  contact  needs  to  provide  a  “count”  of  people  in  the  household  who  want  insurance,  including  himself  if  applying.  The  system  should  be  able  to  count  the  number  of  people  who  are  entered  and  redisplay  them  to  confirm  the  list  is  accurate.    

Recommendation:  Start  by  reconfirming  that  household  contact  is  or  is  not  asking  for  health  insurance  by  saying,  “You  have  told  us  that  you  DO/DO  NOT  want  coverage  AND/BUT  other  family  or  household  members  do.  Next  please  tell  us  the  names  and  date  of  births  of  the  people  who  need  health  insurance.”  After  entering  one  person,  the  prompt  can  be  to  enter  another  person  or  click  “I  am  done”  or  “no  more  people  to  enter.”  In  this  section,  it  is  important  to  give  clear  instructions  on  what  is  meant  by  someone  in  the  family  vs.  household  and  to  reiterate  that  although  other  tax  dependents  must  be  listed  on  the  application,  they  will  have  to  file  their  own  application  to  get  health  insurance.      

 Family  and  Household    This  section  is  extremely  difficult  to  follow  the  logic  and  assess  the  ease  of  use  and  accuracy  for  complex  family  situations.  We  are  concerned  that  there  are  some  discrepancies  in  the  skip  patterns  and  next  steps  and  recommend  that  HHS  do  further  testing  of  complex  families.  We  also  urge  HHS  to  provide  an  opportunity  for  stakeholders  to  be  able  to  review  and  comment  on  a  working  version  of  the  application.  Given  the  difficulty  in  following  the  flow  of  the  skip  patterns,  the  following  may  not  be  a  complete  list  of  areas  that  need  attention.    Question  A3  –  Need  an  alert  that  married  couple  must  file  jointly  to  receive  APTCs,  but  filing  is  not  required  for  Medicaid.      Questions  A11  may  be  particularly  worrisome  to  some  applicants  when  asked  to  whether  someone  else  intends  to  file  taxes  in  a  future  year.      Question  A13  should  specify  that  all  tax  dependents  whether  they  live  with  the  tax  filer  or  not  should  be  included  here.    Questions  A20  and  A21  could  be  confusing.  However,  given  that  it  is  difficult  to  follow  the  

flow  of  this  information,  we  believe  it  is  critically  important  that  stakeholders  be  given  an  opportunity  to  see  a  working  version  of  the  application  and  make  further  comment.      At  first  mention  of  filing  taxes  –  Provide  reassuring  language  that  not  everyone  who  can  get  help  is  required  to  file  taxes.  Clarify  taxes  for  coverage  year  are  filed  in  the  following  year  (Question  A1).      Household  Changes  for  Upcoming  Tax  Year:  Question  28  is  trying  to  see  if  the  household  size  will  change  in  the  coverage  year.  It  will  be  more  accurate  to  probe  with  specific  questions  and  important  for  HHS  to  determine  what  things  it  may  prompt  based  on  information  already  entered.  For  example,  how  does  the  system  deal  with  knowledge  that  a  child  will  turn  19  in  the  tax  year  or  that  there  is  a  pregnant  woman  on  the  application?  Other  questions  could  be  asked  such  as  “are  you  planning  to  get  married  next  year;  will  someone  be  moving  out  of  the  household?  Asking  these  questions  should  be  focused  on  determining  what  the  household  size  might  be  for  both  Medicaid  and  tax  filing  families.    Ultimately,  it  would  be  helpful  for  HHS  to  provide  a  guide  or  details  on  the  system  logic  to  determining  the  different  household  sizes  for  Medicaid  vs.  APTCs.    Examine  Possibility  of  Screening  for  Medicaid  First.  Even  if  you  have  to  establish  whether  the  household  contact  will  file  taxes,  is  there  a  streamlined  way  to  get  at  the  Medicaid  household  first.  In  our  top  priority  issue  comments,  we  provide  a  detailed  outline  of  questions  that  may  fast  track  the  determination  of  the  MAGI-­‐Medicaid  household  size.  Given  time  constraints,  we  were  not  able  to  thoroughly  test  the  logic  and  note  that  there  may  be  other  paths  for  expediting  the  determination  of  this  key  element  in  order  to  screen  for  Medicaid/CHIP  first.  From  this  expedited  section,  the  application  would  continue  to  gather  personal  information  and  citizenship/immigration  status,  followed  by  current  income  to  arrive  a  MAGI-­‐Medicaid  assessment  or  determination.  Further  information  needed  for  APTCs  after  that  point  would  not  be  needed  for  eligible  individuals.    Expedited  APTC  Assessment  for  Single  Adults  With  Tax  Data.  Our  recommendation  for  screening  the  MAGI-­‐Medicaid  household  size  above  will  also  help  the  application  fast  track  a  single  person  and  married  couple  without  children  where  tax  data  is  well  above  the  MAGI-­‐Medicaid  cutoff.  These  applications  could  then  follow  the  route  of  the  expedited  income  determination  for  APTCs.  Keep  in  mind  the  buffer  for  determining  APTCs  must  be  sufficient  to  account  for  all  pre-­‐tax  contributions,  which  may  be  substantial.      Personal  Information    SSN  Alerts  should  clearly  note  how  SSNs  are  used  and  who  needs  to  provide.  We  recommend  dropping  “other  information”  and  specify  citizenship  and  participation  in  other  health  coverage  programs.  Also  delete  the  note  about  the  SSN  helping  with  enrolling  in  a  health  plan,  which  adds  no  real  value  to  this  section.    Race  and  Ethnicity  (move  to  Personal  Information  Section)  –  We  strongly  recommend  that  race  and  ethnicity  be  asked  and  encouraged  for  all  persons  listed  on  the  application,  

whether  applying  or  not.  It  will  be  helpful  to  include  pop-­‐up  alerts  of  non-­‐discrimination,  does  not  impact  eligibility  but  can  be  helpful  in  efforts  to  improve  health  equity  for  everyone.  IOM  Standards  should  be  used  to  collect  race  and  ethnicity  data.  These  recommendations  should  apply  to  approval  for  alternative  applications.    Preferred  Written  and  Spoken  Language  –  It  is  critically  important  to  ask  for  preferred  written  and  spoke  language  for  all  applicants.  This  information  should  be  shared  with  health  plans  so  they  can  accommodate  language  needs  of  enrollees.    Citizenship  and  Immigration  Status    Naturalized  Citizens  –  Add  “I  do  not  know.”  Not  all  naturalized  citizens  will  be  able  to  access  documents  that  were  issued  at  the  time  of  naturalization,  and  rely  on  passports  for  proof  of  citizenship.  Ultimately,  these  individuals  may  need  to  provide  passports  as  proof  of  citizenship  if  passport  information  will  not  accessed  electronically  by  the  federal  data  services  hub.    Eligible  Immigration  Status  –  The  term  could  be  confused  with  a  “status  that  is  eligible  for  immigration’  but  is  intended  to  be  an  “immigration  status  eligible  for  health  insurance.”  We  recommend  that  the  application  clearly  articulate  this.  This  question  should  be  accompanied  by  an  alert  that  it  is  not  necessary  to  answer  this  question  for  non-­‐applicants  and  this  will  not  impact  the  eligibility  of  others.    Question  9  –  This  question  can  be  skipped  in  states  that  have  elected  to  cover  lawfully-­‐residing  immigrant  children  and/or  pregnant  women,  who  are  therefore  exempt  from  5-­‐year  bar.    Other  Addresses    Homelessness  needs  to  be  option  under  Question  2  in  this  section.      Help  Text  should  be  used  to  provide  guidance  for  truly  transient  situations  (families  that  rotate  among  residencies).    Dependents  Away  at  School  –  It  may  be  helpful  to  explain  what  families  need  to  know  about  dependent  children  away  at  school.  We  recommend  moving  related  questions  under  special  circumstances  to  this  section.  

 Special  Circumstances    Questions  1  and  2:  Disability  Screening  –  There  is  insufficient  detail  in  the  question  about  daily  living  activities  to  adequately  screen  for  people  who  may  qualify  for  other  categories  of  Medicaid  but  do  not  have  a  confirmed  disability.  Instead  of  question  2,  the  application  might  present  a  statement  such  as  “Individuals  with  special  health  care  needs  or  who  have  physical,  mental  or  emotional  limitations  or  challenges  may  qualify  for  more  benefits  at  a  lower  cost.  Click  here  to  determine  if  anyone  on  this  application  may  qualify.”  Then  a  pop-­‐up  

sheet  could  appear  that  would  ask  more  questions  such  as  those  used  by  the  American  Community  Survey  to  collect  data  on  disability  status  and  other  child-­‐specific  questions  that  we  also  suggested  for  the  paper  application.    

Recommendation:  Retain  the  question  on  whether  the  person  has  a  disability.  Then  delete  the  question  about  daily  activities  and  insert  a  new  statement  as  noted  in  italics  above.  At  that  point  a  pop-­‐up  supplemental  form  appears  with  this  information.    You  or  a  family  member  may  be  eligible  for  more  benefits  and  lower  costs  if  you  answer  yes  to  any  of  the  questions  below.      

1. Are  you  or  is  anyone  on  this  application  deaf,  or  have  serious  difficulty  hearing?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

2. Do  you  or  does  anyone  on  this  application  have  serious  difficulty  seeing  even  when  wearing  glasses?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?  

 3. Because  of  a  physical,  mental,  or  emotional  condition,  do  you  or  does  anyone  on  

this  application  have  serious  difficulty  concentrating,  remembering,  or  making  decisions?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

4. Do  you  or  does  anyone  on  this  application  have  serious  difficulty  walking  or  climbing  stairs?  Yes  ____    No  ____  If  yes,  who  _____________________________________________________?      

5. Do  you  or  does  anyone  on  this  application  else  have  difficulty  dressing  or  bathing?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

6. Because  of  a  physical,  mental,  or  emotional  condition,  do  you  or  does  anyone  on  this  application  have  difficulty  doing  errands  alone  such  as  visiting  a  doctor's  office  or  shopping?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

7. Is  any  child  on  this  application  limited  or  prevented  in  any  way  in  his  or  her  ability  to  do  the  things  most  children  of  the  same  age  can  do?  Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

8. Does  this  child  need  or  use  more  medical  care,  mental  health  or  educational  services  than  is  usual  for  most  children  of  the  same  age?    Yes  ____    No  ____  If  yes,  who  _____________________________________________________?    

9. Do  any  of  your  children  have  a  medical  condition  that  left  untreated  would  result  in  the  death  or  serious  physical  injury  of  the  child?    

10. Yes  ____    No  ____  If  yes,  who  _____________________________________________________?  

 The  disability  page  should  include  additional  information  on  how  to  get  more  information  or  apply  for  non-­‐MAGI  Medicaid.  It  could  also  include  a  check  box  if  the  applicant  would  like  any  persons  to  be  reviewed  for  eligibility  under  other  categories.    

 Questions  3  and  4:  Students  Away  at  School  –  We  suggest  incorporating  this  question  in  the  “other  address”  section,  which  is  when  parents  would  be  thinking  about  their  dependents  away  at  school.      Question  7  and  8:  Pregnancy  –  If  you  take  our  recommendation  to  do  an  expedited  Medicaid/CHIP  screen  first,  it  will  be  helpful  to  move  these  questions  to  that  section.    Question  9:  Foster  Care  –  Need  pop-­‐up  text  explaining  why  this  information  is  needed.  Suggested  language:  “If  someone  under  the  age  of  26  is  applying  for  health  insurance  was  once  in  the  foster  care  system,  that  person  may  be  eligible  for  more  benefits  at  lower  costs.”    Expedited  Income    Challenge  Question  –  Given  the  vagueness  of  how  this  works,  it  is  unclear  whether  will  be  problematic.    Screening  for  APTCs  –  We  understand  that  an  “income  buffer”  will  be  used  to  ensure  that  no  one  who  is  Medicaid/CHIP  eligible  is  screened  as  APTC  eligible.  It  would  be  helpful  to  understand  how  HHS  arrives  at  determining  the  “buffer”  amount.  Furthermore,  if  any  one  member  of  the  family  including  a  child  that  is  eligible  for  Medicaid  or  CHIP,  the  application  will  not  do  an  APTC  expedited  income  determination.      Projecting  Annual  Income  for  next  Year  –  We  strongly  encourage  the  use  of  a  pop-­‐up  worksheet  to  help  someone  projected  annual  income.  This  worksheet  would  use  logic  and  questioning  similar  to  what  is  in  the  current  monthly  income  section,  allowing  people  to  enter  data  any  number  of  ways.  Additionally,  this  section  must  take  into  consideration  pre-­‐tax  contributions  and  deductions  from  income  such  as  alimony.  Those  questions  could  also  be  asked  in  specifically,  giving  people  the  option  to  enter  the  data  based  on  weekly,  monthly  or  annual  contributions.  The  worksheet  should  be  a  smart  form  that  calculates  the  projected  income  and  enters  into  the  projected  annual  income  field.  To  the  extent  that  this  worksheet  data  can  prepopulate  the  current  monthly  income  section,  it  is  recommended.    Current  Monthly  Income    Definition  of  “Income”  –  It  would  be  helpful  to  include  a  pop-­‐up  that  defines  income  as  “money  you  make  from  jobs  and  wages,  as  well  as  other  sources  of  money  paid  to  you  such  as  social  security  payments.”  Additionally,  specific  questions  or  sources  of  income  should  be  accompanied  by  help  text  or  pop-­‐ups  defining  each  source.    Separate  Current  and  One-­‐time  Income  Questions  –  We  appreciate  that  the  application  

provides  prompts  and  drop  downs  for  entering  income  and  provides  multiple  frequencies.  Recommendation:    Separate  current  and  one-­‐time  income  questions.  

 Question  5:  Self-­‐Employment  Income  –  Need  to  clarify  that  only  “business”  expenses  should  be  deducted.    Income  Frequency  –  Questions  10,  11,  12,  13  and  15  should  have  option  for  reporting  income  that  is  not  received  on  a  regular  basis.    

Recommendation:  Add  varies  or  seasonal  to  the  options  of  payment  frequency  with  ability  to  provide  a  descriptive  answer.  

 Question  15:  Veterans  Payments  –  needs  clarification,  disability  income  is  not  counted  but  retirement  is.    Question  16  and  17:  Deductions  –  These  questions  will  be  difficult  to  answer,  particularly  as  it  relates  to  “other”  deductions.  Additional  pre-­‐tax  contributions  to  childcare,  health  insurance  premiums,  transportation  benefits  and  certain  retirement  plans  should  be  specifically  itemized  in  this  section.  Additionally,  qualifying  deductions  for  alimony,  student  loan  interest  and  other  items  should  be  included.      Discrepancies    The  notes  to  reviewers  indicate  that  this  section  will  appear  if  the  total  attested  income  is  under  the  MAGI-­‐Medicaid  cutoff  but  electronic  data  income  it  is  above.  Likewise,  it  is  critically  important  and  strongly  recommended  that  this  section  be  displayed  when  consumer  attests  income  in  APTC  range  but  electronic  sources  show  Medicaid/CHIP  eligibility.    Overtime,  and  other  common  discrepancies  should  be  reported;  we  recommend  that  the  specific  discrepancies  in  this  section  be  expanded.  

 Health  Coverage  Access  (APTC  eligible)    This  section  needs  explanatory  text  why  this  information  is  needed.  Additionally  “offer”  of  insurance  need  to  be  defined  through  pop-­‐up  text.      Question  4  and  5  –  The  application  should  emphasize  the  difference  between  eligible  for  and  enrolled  in.  Please  also  see  our  comments  regarding  COBRA  on  the  paper  application.  The  online  application  with  the  ability  to  provide  pop-­‐up  information  can  be  more  explicit  about  when  someone  might  be  able  to  drop  COBRA  in  order  to  get  lower  cost  coverage  (if  not  better  benefits)  if  they  otherwise  qualify  for  APTCs.    Employer  Health  Coverage  Information    

Please  see  our  comments  on  the  paper  application  that  apply  to  requiring  that  these  sections  be  completed.  We  prefer  a  simplified  process  that  asks  about  access  to  employer-­‐based  coverage  and  then  requires  an  administrative  process  for  verification  purposes.    Questions  3  and  4    –  It  is  not  clear  at  all  what  is  important  for  someone  to  report.  For  example,  if  a  co-­‐pay  is  going  to  from  $5  to  $10,  does  the  applicant  need  to  report  this?  We  suggest  deleting  this  question.  Alternatively,  there  needs  better  explanation  of  the  kind  of  “changes”  that  the  application  needs  to  know.  These  questions  could  be  combined  rather  than  starting  with  a  yes,  no  question.  Minimally,  “I  do  not  know”  needs  to  be  added  to  the  possible  responses.      Questions  5  and  6  –  We  are  particularly  concerned  about  asking  for  the  name  of  the  lowest  “self-­‐only”  plan  that  meets  “minimum  value  standard”  set  by  the  Affordable  Care  Act.    The  terms  in  quotation  marks  have  no  common  meaning  and  cannot  be  easily  explained  in  order  to  secure  the  correct  information.  Help  text  here  must  be  specific  and  indicate  that  the  applicant  can  submit  the  application  even  if  they  do  not  have  this  information.      Question  7  –  This  question  needs  to  be  specific  in  clarifying  how  much  the  individual  would  pay  to  enroll  the  “employee”  only.    Question  9  –  Whether  the  individual  believes  this  coverage  to  be  affordable  has  no  relevance  to  eligibility.  This  question  should  be  deleted.    Tax  Filer  and  Other  Information    We  recommend  rewording  question  in  text  regarding  why  it  is  helpful  to  provide  an  SSN.  “You  do  not  have  to  provide  a  SSN  but  if  you  do,  it  may  help  us  get  a  better  idea  of  how  much  financial  assistance  you  can  get  in  paying  for  health  insurance  coverage  for  the  people  who  are  applying.”    Medicaid  &  CHIP  Specific  Questions    We  are  hopeful  that  the  final  regulations  will  eliminate  CHIP  waiting  periods  and  that  related  questions  can  be  eliminated.    

 Sign  and  Submit    Statement  2:  Medical  support  –  Repeat  reassuring  language  and  provide  information  on  how  to  tell  agency  of  concerns.    Statement  4:  Renewal  –  This  statement  is  particularly  worrisome.  We  recommend  moving  this  information  to  the  time  when  the  individual  enrolls  in  a  plan.  In  particular,  the  text  regarding  the  Marketplace  will  continue  eligibility  “at  the  level  indicated  by  the  data”  needs  work.  Additionally,  option  4.a.v.  should  be  changed  to  “Do  not  automatically  renew  my  coverage,  please  contact  me  when  it  is  time  to  renew.”    

Statement  5:  Reporting  Changes  –  It  would  be  helpful  to  specify  the  kind  of  changes  (only  those  that  impact  eligibility)  that  need  to  be  reported.  For  example,  “I  need  to  tell  the  program  if  I  move,  have  a  change  in  income,  get  married,  give  birth  or  adopt  a  baby.”  Additionally,  the  notices  will  need  to  clarify  differences  in  what  is  expected  to  be  report  to  Medicaid  vs.  the  exchange.      Statement  6:  Penalty  of  Perjury  –  We  strongly  recommend  that  the  language  used  in  the  paper  application  should  be  used  here.  “I  have  provided  true  answers  to  all  the  questions  on  this  form  to  the  best  of  my  knowledge.  I  know  that  they  may  be  a  penalty  if  I’m  not  truthful.”    Required  Documents    If  documents  are  required  and  not  uploaded,  we  recommend  that  a  cover  sheet,  account  number,  bar  graph  or  other  mechanism  be  used  to  facilitate  the  matching  up  of  documents  that  may  be  mailed  or  faxed  in.      Eligibility  Results    We  strongly  urge  that  Item  3  regarding  withdrawing  the  Medicaid  application  be  removed.  Individuals  who  are  eligible  for  Medicaid  are  not  eligible  for  APTCs.