Transcript Data—A Tool for Targeting

Louisiana Medicaid Eligibility
Improving Work Processes at
the Local Level
Supporting Families after Welfare Reform Learning Session
November 14, 2002
J. Ruth Kennedy, Medicaid Deputy Director
Carolyn R. Norman, Medicaid Area Manager
Louisiana Department of Health & Hospitals
Medicaid Eligibility in Louisiana:
Administrative Factors to Consider
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Medicaid eligibility has been determined by
employees of the state Medicaid agency since 92
Medicaid Analysts process only Medicaid and
SCHIP cases—eligibility for TANF, Food Stamps,
Child Care Assistance is handled by the
Department of Social Services
Medicaid Central Office has direct line authority
over the ~800 eligibility employees in local
offices throughout the state
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SCHIP in Louisiana was implemented as a
Medicaid expansion beginning in 11/98
Seamless process for applicants—No
differentiation between Medicaid & SCHIP
“Many of the ‘Right’ Things”
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One Page Application Form
Mail In Applications
No Face-to-Face Interview Required
No Assets Test
Twelve Months Continuous Eligibility for Children
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* How Many Ways Can You Count
Children Enrolled?
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Enrolled or Recipients
All “New” Children or Net Change in Children
Title 19 Medicaid or Title 21 SCHIP or
Combined
Calendar Month “Snapshot” or Unduplicated
Total
If unduplicated total, for State Fiscal Year or
Federal Fiscal Year or Calendar Year or Since
the Program Began
* With apologies to Robert Browning
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SCHIP (Title 21 Medicaid)
Enrollment for Children Under
Age 19—11/98 to Present
80,000
70,000
60,000
50,000
40,000
47 Consecutive Months
With a Net Gain in Enrollment
for Title 21!!!!!
30,000
20,000
10,000
2-Sep
2-Jul
2-May
2-Mar
2-Jan
1-Nov
1-Sep
1-Jul
1-May
1-Mar
1-Jan
Nov-00
Sep-00
Jul-00
May-00
Mar-00
N-99
S-99
J-99
M-99
M-99
J-99
N-98
Jan-00
0
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Medicaid (Title 19) Enrollment for
Children Under Age 19
480,000
460,000
440,000
420,000
400,000
380,000
360,000
340,000
320,000
2-Aug
2-May
2-Feb
1-Nov
1-Aug
1-May
1-Feb
Nov-00
Aug-00
May-00
N-99
A-99
M-99
F-99
N-98
A-98
M-98
F-98
N-97
Feb-00
300,000
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Net Change in Monthly Enrollment of
Children--Medicaid and SCHIP
14000
12000
10000
8000
6000
4000
2000
0
-2000
-4000
“Houston, we’ve got a problem”
-6000
2-Sep
2-Jun
2-Mar
1-Dec
1-Sep
1-Jun
1-Mar
Dec-00
Sep-00
Jun-00
Mar-00
Dec-99
S-99
J-99
M-99
D-98
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Renewal Woes
A Hole in the Bucket
Closures at renewal--many
for “procedural” reasons-exceeded the number of
new eligibles who were
being added
Problem was more
pronounced in Title 19
population than in SCHIP
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Data “Issues” Facing Louisiana
Medicaid in 11/99
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Medicaid management reports were created based on
needs of AFDC program
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Renewal dispositions were reported at case level, rather than
child level
Emphasis was on timely completing renewal and not letting
the case “expire”; actual disposition was not relevant
Closure reports captured all closures
Previous mainframe software program did not have any
additional “space” to add new fields
Competing priorities--system and/or programming staff
shared with TANF/Support Enforcement/Food
Stamp/Child Care Assistance Programs
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Data Prerequisites for Measuring &
Targeting Retention Efforts
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Specific codes for procedural closure reasons
Educate Medicaid Analysts in importance of
selecting most appropriate code
Capture actual disposition of renewal (rather
than if the renewal was “completed”)
Report variable needs to be the disposition of
child rather than disposition of case
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A Watershed Event -April 7, 2000 SMD Letter
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Clarification and very specific guidance
issued by HCFA regarding ex parte
redetermination requirements
States were directed to review policies,
procedures and practices related to
determination of continued eligibility for
persons impacted by Welfare Reform
 Former TANF recipients
 1931 Population—Families & Children
 4913 Children Who Received SSI
8/22/96 But Are Ineligible Due to New
Definition of Disability
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Ex Parte Renewal Policy Developed
and Implemented
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Major policy changes effective 7/1/00—three
month moratorium on closures while policy was
being written
Procedures for use in implementing the policy
were established
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Use of SDX, Food Stamp, and TANF systems
information
Manager training in new policy, procedures, and
expectations for local office practices
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Another Watershed Event in Early
Summer of 2000
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June 9, 2000 National APHSA Meeting in
Detroit, which focused on TANF/Medicaid
de-linking
Presentations included one by Fred Elig,
regarding Ohio’s reduction in verification
requirements for Medicaid enrollment
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Training for Managers Regarding
Change in Focus at (Then) HCFA
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From strong emphasis on
quality control, error
reduction, thorough case
documentation . . .
. . . To removing barriers,
making enrollment process
“user friendly”, enrolling
eligible children and families,
assuring loss of cash does not
translate to loss of Medicaid
as well.
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Factors Contributing to Change in
Focus & Priorities
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Universal health care debate in
1994 was a catalyst for
recognizing the importance of
health insurance and further
research.
Welfare reform de-linkage and
resulting unintended huge declines
in Medicaid caseloads—State by
State review in fall of 1999.
Passage of State Children’s Health
Insurance Program and problems
in enrolling eligible children.
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Legacy of Onerous Verification
Requirements in Louisiana
“She was one of those
“[welfare] oriented
workers" last year. I had
the hardest time with her
with application
simplification, because
she was one that "grew
up" making the clients
verify everything but the
air in their tires.
--Medicaid Analyst Supervisor
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Medicaid Verification
Requirements, Circa May, 2000
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Our Medicaid verification
requirements were copied from
AFDC verification requirements
Tough sanctions for first 30 years
of Medicaid Program for
exceeding 3% error tolerance
level
QC error findings required
corrective action implementation
to avoid sanctions. These often
involved additional information
gathering and documentation
requirements for case records.
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Result of 25 Year Focus on Quality
Control and Case Validity
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Important Income Verification
Issues Medicaid vs. TANF/Food
Stamps
Medicaid
TANF/Food Stamps
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Benefit level as well as
eligibility is being
established
Preciseness of income
projection is always of
extreme importance
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For most programs,
benefit level is not a
factor, only eligibility
If income is clearly below
the maximum and
eligibility is established,
exact amount is not
critical
Exceptions are Long Term Care, and
Spend Down Medically Needy
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Radical Changes in Verification
Requirements Effective 7/2000
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Allowed for self-declaration of citizenship,
residence, unless questionable
Social security cards not to be requested if
number provided
Other systems (Food Stamp, TANF) could be
used to verify age
Reduced income verification period from 8
weeks to 4 weeks PLUS established the concept
of “reasonable certainty” in income
determinations
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Additional Focus on Retention
During 2001
Retention was a major issue at February
2001 Covering Kids regional meeting in
Arlington, VA we attended. It was the
catalyst for additional changes in 2001”
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A “new name”—changed name of the process formerly known as
“redetermination” to “renewal”
New simplified Renewal Form
Requested that Regions design and implement projects to improve
renewal outcomes
“Best practices” shared
Ex parte renewals for children with active Food Stamp cases
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Ex Parte Eligibility Renewals for
More Children
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Expanded ex parte renewal policy to apply to all
children with active Food Stamp case effective
7/1/01. In essence, “adjunctive eligibility”
Notice developed to advise families that we have
established their continued eligibility for 12 more
months
Established “new” renewal code (Code 11) to
identify ex parte renewals
Over 25 % of all Title 19 renewals in October
were completed without the family being
required to complete & return a renewal form
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Telephone Follow-up When
Renewal Form is Not Returned
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Policy changed to require
an attempt to contact by
telephone prior to
closure, beginning 7/1/01
Local office examples of
“customization” of policy
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At least one call should be
before 7:00 A.M. or after
5:00 P.M.
Confirm current mailing
address and phone number
at point of ANY contact
with the household
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Local Office Involvement in Developing
Retention Improvement Plans
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Participating in workgroup resulted in greater
awareness of the problem (education/training)
Front-line staff have unique insights and
proposed excellent strategies
Ownership and buy-in was achieved
“I think one of the highlights staff enjoyed was
being able to come up with a renewal plan, and
then watch their ideas at work”
-- Debbie Falgout, Medicaid Analyst Supervisor
Thibodaux, Louisiana
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Examples of Local Initiatives to
Improve Retention & Enrollment
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Supervisory review of all procedural closures at renewal
Not requesting ANY verifications at renewal
Adding a “drop box” outside the building for after hours
convenience to return renewal forms, verifications
Additional “reminders” e.g. fluorescent pink reminder
flyer prior to advance notice of closure
Enclosing another renewal form/SASE with advance
notice of closure
Using US Postal Return Service
Telephone surveys of families who failed to return the
renewal form
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Incremental Changes in Reducing
Verification Requirements
Age
Relationship
April, 2002
Voluntary Child Support
July, 2001
Citizenship
Louisiana Residence
July, 2000
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“New Thinking” in Local Offices
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“What is making a difference is staff has
changed their way of thinking and they do bend
over backwards to help the recipient. The
mindset is that the applicant or recipient is our
number one priority. . . .the Analyst continues to
extend time when the recipient states he or she
needs more time to get the information in. The
Analyst will help the recipient to gather
information or documentation whenever
possible.”
--Margo Joseph, Medicaid Area Manager
LaPlace, Louisiana
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Some “Lessons Learned” Relative
to Data
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Invariably, the data someone is requesting is the
one item not available on an existing report
Validity of data is very much influenced by end
users—education regarding how data will be
used and the need for accuracy is critical
Refinement of data collection and back end
reporting is a fluid process—needs change, new
questions need answers
Too much information is problematic; to be
useful, data needs to be in a easily interpreted,
comprehensive, and concise format
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Conclusions from 6/00 “Who Moved the
Cheese?” Training Remain Relevant
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They HAVE moved
the cheese.
The quicker you let
go of old cheese, the
sooner you can enjoy
new cheese.
They keep moving the
cheese so be ready to
change quickly!
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Ongoing Evaluation of Policies,
Procedures and Practices
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Some policies and procedures have unintended
consequences, or in retrospect prove to be
unnecessary;
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Example: policy to hold renewals and not close them
for procedural reasons until deadline day for closures
“Best practices” need to be identified,
documented and shared with other offices
Good renewal outcomes by regions and offices
deserve acknowledgement and recognition
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For Additional Information on
Louisiana Medicaid Local Processes
Ruth Kennedy
Medicaid Deputy Director
Louisiana Department of Health & Hospitals
P.O. Box 91030
Baton Rouge, LA 70821-9030
Telephone: 225 342 3032
Fax: 225 342 9508
E-Mail: rkennedy @ dhh.state.la.us
Carolyn R. Norman
Medicaid Area Manager
Tangipahoa Parish Medicaid Office
121 Robin Hood Drive
Hammond, LA 70403
Telephone: 985 543 4217
Fax: 985 543-4221
E-Mail: cnorman @ dhh.state.la.us
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