(Note: For a footnoted version of this article, please download the pdf issue of BIFOCAL Vol. 34, Issue 6.)
The Affordable Care Act (ACA) envisions a single, streamlined, electronic application and verification process for health coverage that remedies many of the challenges and inefficiencies that exist in today’s public benefits system. The law also ensures that individuals and families can obtain coverage in multiple ways by requiring states to accept applications online, in person, by mail, and by telephone. This policy brief focuses on the critical role that telephonic signatures, or “spoken signatures,” can play in the success of each state’s telephone application process. States must prioritize the adoption of telephonic signatures now to ensure that new state IT systems will be able to develop this technology for use by exchange call centers, navigators, and assisters before open enrollment begins in October 2013.
A recent three-state study conducted by Lake Research Partners found that nearly as many low-income people want assistance by telephone as in person, and almost twice as many want help over the phone compared to those who want help online. This research suggests that phone applications will be especially important to supporting enrollment in health insurance that will be available to individuals and families in 2014 (Medicaid, the Children’s Health Insurance Program (CHIP), and coverage through a health insurance exchange).
A telephonic signature is a type of electronic signature that uses an individual’s recorded verbal assent in place of an ink signature, and it is considered legally enforceable in both the private and public sectors under certain conditions. In addition to significant use of telephonic signatures in the private sector, the federal government has been testing various ways to implement telephonic signatures since the 2008 Farm Bill, which allowed state agencies to accept “spoken signatures” for the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program). The goal of this rule change was to develop a more efficient and cost-effective application process for individuals and government agencies by allowing SNAP applicants to avoid the lengthy and often unreliable mail exchange to submit ink signatures.
A review of various approaches to implementing telephonic signatures approved by the U.S. Department of Agriculture (USDA) provides useful insight into the kinds of technology that work best for consumers (see table opposite).
While the federal government has allowed states to accept electronic signatures for Medicaid and CHIP for several years, the Affordable Care Act will require states to accept electronic signatures in 2014. Subsequent regulations from the Centers for Medicare and Medicaid Services (CMS) confirm that “electronic, including telephonically recorded, signatures and handwritten signatures transmitted via any other electronic transmission must be accepted.” Because the law requires exchanges, Medicaid, and CHIP to use a single, streamlined application, and because the exchanges must accept applications via telephone, the telephonic signature requirement also extends to the exchanges.
CMS is expected to issue detailed guidance around the use of telephonic signatures in the coming months, and it has stated that forthcoming regulations will allow states significant flexibility. Even so, CMS will likely require states to ensure that telephonic signatures are transferable to and among relevant entities (i.e., from the exchange to the Medicaid or CHIP agency, and vice versa). Such a requirement would ensure that all relevant application information travels between agencies in a single case file and that applicants are never required to submit duplicate information.
It is important to note that states with federally facilitated exchanges (FFEs) may implement the telephonic signature provision differently than those with state-based exchanges, since the responsibility for collecting and accepting telephonic signatures will fall primarily on the federal government and its exchange call center. That being said, states with FFEs must still prepare to accept telephonic signatures into their Medicaid and CHIP eligibility systems, since states will maintain control over both programs.
Effective assistance over the phone will play a key role in ensuring that health reform reaches the millions of Americans who will be newly eligible for coverage in 2014. Whether states are operating their own exchanges or partnering with the federal government, they can benefit from seeking out best practices in telephonic assistance and engaging diverse stakeholders to make the most of state IT development. ■