Retention Initiative Group Conference Call June 11, 2008 J. Ruth Kennedy La. Dept of Health & Hospitals

2 “A Rising Tide Lifts All Boats” —John F. Kennedy Improvements to SCHIP Renewal Process & Retention Improvements to Medicaid Renewal Process & Retention

3 Our Moment of Reckoning—Net Loss of > 6,000 Kids in November A-98 N-98 F-99 M-99 A-99 N-99 Feb-00 May-00 Aug-00 Nov-00 Feb-01 May-01 Aug-01Nov-01 Feb-02 May-02 Aug-02 Nov-02 Feb-03 May-03 Aug-03Nov-03 Feb-04 May-04 Aug-04 Nov-04 Feb-05 ”Houston, we’ve got a problem”

A “Hole in the Bucket” or Renewal Woes 4  Children closed at renewal can easily exceed new children added  Many closures for “procedural” reasons  Failure to return renewal form  Failure to submit essential verification  Unable to locate—mail returned  Problem more pronounced for--  Medicaid children  Non-English speaking families

5 Six Ways Procedural Closures at Renewal Can be Reduced  Aggressive follow-up when renewal form is not received  Ex Parte renewals  Telephone renewals  Automated Voice Response (AVR) renewals  “Administrative” renewals  Web renewals

6 Aggressive Follow-up When Renewal Form is Not Received  Incorporated into policy and procedures in 7/01  Efforts to find new address and locate family  Other computer systems  Internet  Schools, medical providers  Phone calls must be attempted and documented  First-line supervisors make (& document) attempts as well  Major enrollment losses when discontinued from 7/06 to 11/06

Alternatives for Renewal That Do Not Require Form Renewal MethodImplementation Date Ex Parte for SSI or TANF ClosureJuly, 2000 Ex Parte with Active Food StampsJuly, 2001 Telephone & Off CycleNovember, 2003 Automatic Voice Response (AVR)July, 2006 InternetDecember, 2007 Ex Parte without Active Food StampsJanuary, 2008 Administrative for Low Risk CasesJuly, 2008

“Paths” to Renewal for LA Children in May 08

9 A Watershed Event -- April 7, 2000 SMD Letter  HCFA [CMS] guidance on ex parte redeterminations  States directed to review policies, procedures and practices  Identify any “unintended consequences” of welfare reform  Ex parte redeterminations defined

10 Ex Parte Renewal Defined  “Action by one party without the involvement of the other for verification“  Heavy reliance on other computer systems for verification  Food Stamps  TANF  Child Support  Commercial service The Work Number

Ex Parte Renewals Using Food Stamp Data  Mandated statewide effective July 2001  High level of confidence in Food Stamp income data  Caseworkers still play major role in decision making  Dramatic reduction in procedural closures at renewal  Single largest factor in decreasing procedural closures 11

Ex Parte Renewals Using Work Number and/or State Tax Data  Implemented effective January 2008  “Parallel” testing using these sources and actual verification  Conditional  Active earnings and  If 2 parents in home, systems must show active earnings for both  Not applicable for Section 1931 (our parent program with 12% income cap)  Extensive testing to develop profile within our error tolerance (3%) 12

13 We Made a Conscious Decision to Change Direction  From historic emphasis on quality control, error reduction, thorough case documentation... ... to removing barriers, making enrollment & renewal process “user friendly,” increasing enrollment of eligible children and families, assuring loss of cash did not translate to loss of Medicaid as well.

How Good is Good Enough????  Defined degree of risk we could accept  Caseworkers empowered to use judgment  “Reasonable certainty” rather than absolute certainty  Net cost of simplified renewal vs. cost for ineligible benefits for small percentage

Impact of Ex Parte Renewals on Eligibility Accuracy  Ongoing eligibility monitoring  Monthly QC review of SCHIP & Medicaid renewals  PAM pilot state with eligibility component  Legislative Auditor reviews  Error rate well below our 3% tolerance threshold  Data driven profiling -- cases with acceptable level of risk  Greatest vulnerability is overestimating income & placing in SCHIP

Questions???? Ex Parte Renewals

17 Telephone Renewals Benefit Families and the Agency  Federal regulations require annual review—not signed form  Implemented 11/03 as option when ex parte can’t be done  Has evolved from “cold calls” and follow-up to “time to renew/call me” letters  Key to getting procedural closures even lower  Major reduction in administrative cost—postage, paper, staff time  Families love it!

18 Automated Voice Response Renewals  Families can renew anytime—off-cycle or “rolling” renewals encouraged  Option available when calling the LaCHIP toll free hotline  Renewal letters include information on this 24/7 option  “To renew by phone now, Press 3”  Data retrieved daily & electronically routed to local eligibility offices  Voice recognition software coming next month

Administrative Renewals for Select Cases Beginning 7/08  Relationship other than parent (kin/non-kin caregivers whose income does not count)  RSDI income  One parent household with stable unearned income (usually child support)  No change in eligibility in last 3 years and net income < $500 Eligibility system data analysis indicates very low likelihood of closure due to income for cases with these characteristics.

Administrative Renewals [Semantics Do Matter] Self-Declaration Passive Renewal Express Lane 20

Questions???? Telephone, AVR & Administrative Renewals

22 Data is Essential to Effectively Monitor Renewal Outcomes  Monthly Procedural Closure report since March 2001  Focus is on  children rather than “cases”  actual outcome and not just “done” or “expired”  Report is distributed via to all eligibility staff with commentary  Critical for measuring improvement and monitoring  Correct caseworker coding is critical

23 Beware the Watchman!! “The government are very keen on amassing statistics. They collect them, add them, raise them to the Nth power, take the cube root and prepare wonderful diagrams. But you must never forget that every one of these figures comes in the first instance from the village watchman, who just puts down what he... pleases.” --Sir Josiah Stamp, Head, Bank of England Yikes!!

The Bottom Line — What it Means for Louisiana Kids! ProgramChildren Due for Renewal Closed –Failure to Locate/Complete Renewal Procedural Closure Percentage LaCHIP9, % Medicaid30, % Actual Totals for 5/08 39, % At 3/01 Procedural Closure Rate 8, % 8,000+ more children renewed as a result of our changes

Policy Changes to Support New Renewal Methods  Signed form not required to review eligibility  Eligibility can be renewed anytime (rolling or off-cycle renewal)  Not necessary to send a renewal form prior to closure  Reasonable certainty verification standard  Verification not required unless declared income is within 25% of limit

Questions???? Renewal Data & Policy Issues

27 “They’ve Moved the Cheese!” Training for Supervisors in May 2000  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!

28 Our Internal Marketing Messages to Eligibility Staff  Why health coverage for kids is important  to child  to family  to State  to society  Barriers to getting and staying enrolled  Misinformation/lack of knowledge  Literacy  Parental apathy is not the child’s fault

29 Local Office Involvement in Developing Retention Plans  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

30 Examples of Local Office Initiatives  Supervisory review of all procedural closures at renewal  Not initially requesting any verifications at renewal  Adding a “drop box” outside the building for after hours convenience  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  Calls outside normal working hours

31 Evaluation of Policies, Procedures and Practices  Ongoing evaluation of policies, procedures and practices a must  Some policies and procedures have unintended consequences  Some policies and procedures don’t work!  “Best practices” need to be identified, documented and shared  Good renewal outcomes deserve acknowledgement and recognition

32 “New Thinking” in Local Offices  “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

WorkSmart!- Our Eligibility Process Improvement Initiative  Identify problems  Brainstorm possible solutions  Test solutions on a small scale (to see if it works!)  Implement improvements  Local offices  Geographic regions  State level  Continuous & statewide 33

Some Major Successes from WorkSmart!  Even fewer procedural closures at renewal  Completing renewals well in advance of deadline  Identifying and eliminating unnecessary work  Sense of empowerment for eligibility managers and caseworkers  Catalyst for official state policy changes 34

Acknowledgments & Disclaimers The Fine Print  Louisiana Medicaid/SCHIP eligibility is totally separate from Social Services  State employees rather than county-based system  “We” have direct line authority  Medicaid & SCHIP eligibility policy  Medicaid eligibility systems  Medicaid eligibility employees in 9 regional & 46 local offices  An amazing eligibility management team  Unwavering commitment and encouragement from Executive Management

36 “Closing the Door” on Procedural Closures at Renewal Matters  Closures can exceed new adds = net loss of insured children  Essential to “maintain the gains”  More costly to process applications than renewals  Protect investment in outreach

37 Lessons Learned from our Renewal Transformation  Incremental change is OK  Make certain people know why  Focus on administrative as well as health & social benefits  Empowerment of state government employees pays big dividends  Don’t be afraid to establish high expectations for staff  Expect initial (and ongoing!) pushback  It is definitely worth the effort

38 Ruth Kennedy LaCHIP Director & Medicaid Deputy Director Louisiana Department of Health & Hospitals P.O. Box Baton Rouge, LA Telephone: Fax: Never doubt that a small group of thoughtful, caring people can change the world. Indeed, it is the only thing that ever has ! — Dr. Margaret Mead