In October, state health insurance exchanges (HIX) will start enrolling Americans for coverage as required by the Affordable Care Act (ACA). That’s good news for people with computers and broadband connections, who should have an easy time accessing state exchange portals to compare offerings, determine eligibility, enroll in plans and pay premiums.

But many who rely on smartphones for Internet access will have to choose a different way to apply for coverage, at least this year.

“We did have an extensive discussion around mobility and mobile access to our exchange early on,” said Curtis Kwak, CIO of the Washington Health Benefit Exchange. “Because the timeline was engraved in concrete for Oct. 1, we didn’t get a chance to build that into our version one application. But it’s definitely queued up for version two, which is planned for an August 2014 launch.”

State leaders understand that smartphones play an important role as Internet access tools, but in the scramble to get their HIXes up and running by October, most states haven’t yet tackled the question of mobile access.

But smartphone use for Internet access is particularly high among some of the groups most likely to look to HIXes for health coverage because they aren’t getting it through employers.

Of adults who use their cellphones to access the Internet, 45 percent of 18- to 29-year-olds, 51 percent of African Americans and 42 percent of Latinos do most of their online browsing that way, according to the Pew Research Center’s Internet & American Life Project. People in households that earn less than $50,000 a year and people who haven’t graduated from college also are likelier to rely on mobile phones to get online, Pew said.

“[States] are finding themselves behind the eight ball as far as being ready for the exchanges. So they’re not as focused on the newer technology,” said Jinnifer Wattum, director of eligibility and exchange solutions for Xerox Government Healthcare Solutions.

People who lack Internet access will be able to interact with HIXes in other ways like calling customer service centers or mailing paper forms. And smartphone users won’t be entirely out of luck either.

Citizens will be able to use their mobile phones to read material on state exchange portals and perhaps to conduct some transactions. But which functions they can use, and how easily, will vary by state.

Watch video (above): Massachusetts' Health Insurance Exchange Focuses on Reusability

“The good news is that the health benefit exchange interface is not a very heavy interface,” said Manu Tandon, secretariat CIO at the Massachusetts Executive Office of Health and Human Services. “Our idea in general is to make the amount of information we ask of citizens, especially if we’re asking the second time around, as minimal as possible.”

The Massachusetts HIX interface will contain a minimal number of data fields, Tandon said. It could become even simpler as the state’s system starts to pull more data from a hub that the federal government is building to supply data to state exchanges in real time.

If citizens don’t need to enter a lot of information, they might be able to conduct transactions through the browsers on their smartphones, he said.

Massachusetts comes to the ACA with a strong advantage: Most of its residents already have health insurance, thanks to legislation the state enacted in 2006. When its new ACA-compliant HIX opens for business, most residents will use it to renew or change their coverage, not to enroll for the first time, Tandon said. Massachusetts will need to collect less data than typical states, so more residents will be able to use their smartphones to complete the tasks.

But in most other states, residents seeking health coverage will need to complete a lengthy form. The “streamlined application” — a single form used to apply for Medicaid, the Children’s Health Insurance Program and health insurance plans offered on state exchanges — is complex, said Bruce Caswell, president and general manager of health services at Maximus, a Reston, Va.-based company that partners with local governments to provide health services for poor communities. “That might not make it suitable to be completed on a mobile device.”

So what will Americans be able to do on their smartphones when HIXes open in October?

Nevada Targets Tablets

Smartphones aren’t the only mobile devices citizens can use to access state health insurance exchanges. Nevada is working to accommodate tablet computer users to interact with its Silver State Health Insurance Exchange.

"Tablets have a screen size that will allow for the comparison of plans side by side, and all the things that go along with the plan,” said C.J. Bawden, communications officer of the Silver State Health Insurance Exchange. The much smaller screens on smartphones don’t easily allow for that kind of activity.

Nevada is designing its exchange’s interface to display well on standard computers and tablets, Bawden said. ”We are going to move forward into development of an app or development of a mobile site, in future years, to make it easier for a person with a tablet to walk through all of the steps.”

In the exchange’s early years, Nevada will analyze how long it takes to navigate the site and where users encounter problems to improve the site across various devices.

Tablets could also become an important tool for navigators, or people who, under provisions of the Affordable Care Act, will educate individuals and small employers about health plans and help qualified individuals enroll. In Nevada, many of the navigators who guide citizens through the exchanges carry tablets, Bawden said.

Bruce Caswell, president and general manager of health services at Maximus in Reston, Va., said that navigators might become the real force driving adoption of mobile technology for health insurance exchanges.

"”I think that an iPad or tablet-based, downloadable app that individuals in the field can use in a comfortable setting to educate, communicate and then help navigate the process is going to be critical,” he said.

In states like Nevada, where vast areas of sparsely populated territory lack broadband and wireless service, navigators who visit residents during open enrollment periods might need other mobile technologies as well, said Bawden. ”We’re looking at putting together a truly mobile system, possibly with a vehicle with a satellite uplink to drive out to these remote locations.”

If consumers are using an iPhone or Android phone with a larger screen, they’ll be able to navigate the exchange Web page, said C.J. Bawden, communications officer of Nevada’s Silver State Health Insurance Exchange.

In some states, including Nevada, users of both smartphones and feature phones will be able to get text messages reminding them about premium due dates, open enrollment windows and other important deadlines.

“You’re going to have the ability through the Web portal to choose your preferred method of contact, whether that’s by SMS [short message service], email, a telephone call or regular mail,” Bawden said.

Xerox is developing Nevada’s exchange and Web portal, and the company created a function that reminds consumers when a payment is due.

“As long as the client has given their authorization and mobile number, we can put it on their account that 10 days before their premium is due, a text message will go out,” said Wattum. “They would have to go into the website to pay their premium, but it does give them a reminder via text that they need to do that.”

Rather than make smartphone users fend for themselves on their full-blown HIX portals, some states will most likely build mobile-optimized versions of those sites with simplified interfaces, said Caswell. Smartphone users probably won’t be able to complete entire applications on those mobile sites, but they’ll be able to go through the preliminary eligibility screenings.

“You might even see a relatively straightforward way to do health plan comparisons, at least at a basic level of comparing product costs and features,” he said. “But with the expectation that for a lot more detail, you’d have to go to a bigger browser version.”

While Massachusetts won’t create a separate mobile site in the first incarnation of its new portal, the state is taking mobile browsers into account, along with popular big-screen browsers, as it designs the interface.

“You always have this problem that you want to have the same content be presentable using different presentation media,” Tandon said. “This is no different.”

States could make more specific accommodations for smartphones starting in the next year or two. “I think what you’ll see in the first quarter of next year are mobile applications for paying a premium and making simple changes,” Wattum said.

Based on her conversations with officials in various states, Wattum said it seems that most users won’t be able to shop or apply for plans entirely from their smartphones until late 2014 or 2015.

Massachusetts is still confirming plans to add mobile functionality, said Tandon. “Our current thinking is to develop a mobile Web application for the state-based exchange using Oracle’s ADF Mobile product, which would support the iOS and Android OS using the same code base.”

That application probably would work best for functions like calculating insurance subsidies, managing a user account and paying premiums, Tandon said.

“Other functions, such as applying for health insurance, would be a lengthy process and may not be a good fit for mobile apps,” he said.

In Washington, Kwak envisions someday offering a mobile app that users could download for free from the Washington Health Plan Finder website or a commercial app store. But it’s not yet clear whether downloadable apps are an effective way to reach the state exchange’s target market, he said.

State officials also must remember that mobile apps carry a cost, Kwak said.  “I think there’s some perception out there that mobile applications are a dime a dozen,” he said.

That might be true for users who download the software, but it’s not the case for the organization that has to develop, test and market the app. “I want to be sensitive to the fact that there is major work in developing even the simplest mobile application and making it available to the public,” he said.

Smartphone interfaces for health and human services already exist outside the realm of HIXes. For example, Maximus has developed a downloadable app for people receiving Temporary Assistance for Needy Families benefits in Wisconsin to demonstrate that they are seeking employment.

“You can use this mobile app to submit time sheets, to document your job search activity — literally taking pictures of the business cards from in-person interviews you’ve had,” Caswell said.

On the health-care side, this year Maximus will pilot the use of a mobile-optimized Web browser in some of the states where it provides services for the Children’s Health Insurance Program and Medicaid programs. Beneficiaries with smartphones will be able to use this browser to perform some basic activities, such as looking up health-care providers, Caswell said.

However, mobility, in general, has been making its way into the health benefit market at a glacial pace, Caswell said. HIXes provide a chance for catch-up.

While states are busy just getting their HIXes and portals up and running, they also realize that many of the citizens they’re trying to bring onto the exchanges are people under 30 who rely heavily on their smartphones, Caswell said.

“You need to have those folks in the exchanges, because from an actuarial perspective they’re critical to ensuring that the exchanges are sustainable,” he said.

It’s certainly time for a greater emphasis on mobility, agreed Wattum. In the past, organizations providing services to low-income and uninsured populations assumed that those clients lacked access to computers or weren’t technically savvy.

“That’s just not the case,” said Wattum. “And especially in the last three years, mobile devices have become the norm for every population.”

States need to figure out how to provide services through mobile devices, she said.

Like Tandon in Massachusetts, Wattum looks to the federal health-care data hub to pave the way for better smartphone access in the future.

When an applicant enters basic information, such as a name, Social Security number and current address, the federal hub will use that to verify citizenship, pull income figures from the IRS and otherwise retrieve data needed to apply for insurance and government subsidies, she explained. If the hub supplies that data, states won’t need complex on-screen forms to capture the information from applicants.

At least, that’s the theory. “States are hesitant about whether or not that’s truly going to be real time and whether it will be ready for this fall,” Wattum said. “Once that automation is proven out, I think the states and the federal government will be more open to investing in technology such as a mobile app.”

Photo of Manu Tandon by David Kidd

Merrill Douglas  |  Contributing Writer