people without a fixed address. These shifts in the size and makeup of the eligible population will contribute to the need for a robust consumer assistance program that includes the “human touch” that people often need to navigate complex systems. Very few states have such personalized support for their eligible populations. The ACA has recognized this challenge and has provided grants to states to augment their consumer assistance programs.

Many states have done fairly well in accommodating individuals with disabilities, Weiss said, but they have not yet adapted programs to meet the needs of individuals in terms of language and literacy. One in 10 Americans does not speak English as a first language. Consequently, states will need to implement translation programs and programs that will support the needs of individuals with limited English proficiency. Families that include individuals with different citizenship statuses will present a challenge to states. Some families may include one parent who is an undocumented immigrant, another parent who is a legal immigrant, and children who are American citizens. It will be difficult for states to communicate to such families how their right to coverage may vary by program. In addition, there will be families with one privately insured parent and other family members without dependent coverage under the policy who will need help accessing public programs.

Helping people understand their eligibility is going to be particularly challenging, Weiss said. Coverage gaps have been well documented (Sommers and Rosenbaum, 2011). Half of low-income individuals under 200 percent of the federal poverty level experience income changes over the course of a year. Of these individuals, half will experience more than one, and as many as two to four changes in a year. Every time an individual’s income changes between 138 percent of poverty and above, there will be a potential transition in coverage. It will be challenging for states to manage these transitions, Weiss said. This will be especially difficult when individuals are required to reimburse the federal government at the end of the year for any subsidies they receive, such as when they are found to be ineligible for coverage for some portion of the year.

The ACA requires states to adopt technology that allows individuals to apply for health insurance coverage online, in person, by mail, or by telephone. All states have developed an online application for either Medicaid or the Children’s Health Insurance Program (CHIP); however, in many cases the application must be printed, signed, and then faxed or mailed for processing. Some states have a system for electronic submission of the application; however, relatively few states allow the applicant to complete the entire process online. Fewer than 10 states have systems in place that electronically match information submitted by the applicant to administrative records, Weiss said. Such systems eliminate the need for



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