1. 21 st -century enrollment and retention Families USA: Health Action 2010 January 28, 2010 Stan Dorn The Urban Institute

2. 2 Overview Whats so special about the 21 st -century? Examples Massachusetts Louisiana Express Lane Eligibility

3. Part I Whats so special about the 21 st Century?

4. 4 Computers! The government has lots of data about us Its cheap for computers to exchange information If public agencies have sufficient data to qualify people for health coverage, what value is added by having families complete largely redundant paperwork? And what is the cost?

5. 5 The miracle of data-driven eligibility: access PLUS integrity and efficiency U.S. Government Accountability Office: Improved information systems, sharing of data between programs, and use of new technologies can help programs to better verify eligibility and make the application process more efficient and less error prone. These strategies can improve integrity not only by preventing outright abuse of programs, but also by reducing chances for client or caseworker error or misunderstanding. They can also help programs reach out to populations who may face barriers. -GAO, Means-tested Programs: Information on Program Access Can Be an Important Management Tool, 3/05, GAO- 05-221

6. 6 What else is so special about the 21 st century? Behavioral economics, of course! Basic concept: human beings are not fully rational

7. 7 Example #1: Retirement savings Sources: Laibson (NBER), 2005.

8. 8 Example #2: The leaving $100 bills on the sidewalk study 49% of older employees at 7 private companies failed to fill out the forms required to obtain their employers matching contributions to 401(k) accounts, even though participation would have cost the workers nothing. Left on the table was 1.3% of annual income, on average. Financial education had almost no effect, raising participation rates by just one-tenth of one percent. Source: J. Choi, D. Laibson, B.C. Madrian, $100 Bills on the Sidewalk: Suboptimal Saving in 401(k) Plans, National Bureau of Economic Research Working Paper 11554, August 2005.

9. 9 Why? Confusion Discomfort Competing priorities Procrastination

10. 10 A golden rule of behavioral economics:

11. 11 Applications? We dont need no stinkin applications!

12. Part II Examples: Boston enrollment, Baton Rouge renewals, and The Express Lane

13. 13 Boston: enrollment Preliminary findings from a SHARE grant funded by the Robert Wood Johnson Foundation

14. 14 Coverage expansion in Massachusetts Extraordinary results. Only 2.6 percent of state residents were uninsured in 2008 Well-known policy changes Medicaid and Commonwealth Care (CommCare) Adults mandated to have coverage o Exception for those unable to afford it Health insurance exchange offers multiple private plans

15. 15 Eligibility often established based on data matches, not applications Automatically found eligible for CommCare, based on free-care pool data No need to file application Enrollment into MCOs: Notice of eligibility, encouraged to pick MCO Auto-assignment to MCOs, if eligible for premium- free coverage Huge initial impact of auto-conversion Month 6, > 80% of all CommCare enrollment After 15 months, nearly 100,000 auto-converted enrolleesroughly 1/4 th of all increased coverage

16. 16 Eligibility determination On-line application form (virtual gateway) Trained staff + computer routines=cheaper processing The application form must be properly completed for a hospital or clinic to get paid State does not pay providers for this work Provider or CBO becomes the applicants authorized representative, copied on all eligibility-related notices Efficiency gains – roughly doubled caseload before 2006 reforms while growing administrative staff < 10% But: up-front transition costs, both financial and cultural From 2006-2008, more than half of all successful applications came via the virtual gateway

17. 17 Baton Rouge: renewals

18. 18 Renewal procedures Standard approach Send household a renewal form asking for information about current circumstances If form not completed, terminate coverage As a result: In some states, as many as 50 percent of children lose Medicaid and CHIP at renewal Roughly 40 percent of eligible but unenrolled children received Medicaid or CHIP the prior year

19. 19 LaCHIP renewals for children Eligibility determined based on Data from state-accessible records Where income is stable, administrative renewal Proactive telephone calls Traditional form completion is a last resort The results Procedural terminations < 1% Total terminations – 4.5% Only 3% of renewals require form completion PERM Medicaid Eligibility Error Rate is 1.54%, or one-fourth the national average

20. 20 The final example

21. 21 Express Lane Eligibility (ELE) New state option in Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Basic idea: if another government agency has found a child to have a characteristic (e.g., income below a certain level) relevant to Medicaid or CHIP eligibility, that finding can meet the applicable Medicaid/CHIP eligibility requirement Differences can be disregarded: ELE is allowed even if eligibility methodologies differ between Medicaid/CHIP and the other program Multiple uses: ELE can be used for both initial determination and redetermination

22. 22 Key limits and requirements May not use ELE to establish citizenship. Required: advance notice and chance to opt out May not use ELE to deny eligibility Standard procedures available as a back-up if ELE does not establish eligibility Screen and enroll applies – however, special options : Threshold approach. A state can set a threshold 30 FPL percentage points above the standard Medicaid eligibility limit. Based on whether the ELA says the child is above or below the threshold, the child goes into CHIP or Medicaid.

23. 23 Potentially promising uses of ELE State income tax forms CHIPRA specifically allows ELE based on income tax forms and data 86.3 percent of all uninsured file federal income tax returns; probably same order of magnitude with state income tax returns Nutrition programs More than 70 percent of uninsured children below 200% FPL live in families who participate in the food stamp program, the National School Lunch Program, or WIC. 1115 waivers for ELE? Childless adults already require waivers. Why not add ELE? For parents, may be worth raising to CMS

24. 24 Conclusion Avoid the need for paperwork from consumers to establish and renew eligibility, whenever possible Shape eligibility rules based on available data Give public agencies a strongly proactive, not a passively reactive role in qualifying individuals for coverage But: Simplification isnt simple (Ruth Kennedy, LaCHIP Director) Persistence and creativity will be required

25. 25 Where to find more information about various topics? 21 st -century eligibility, enrollment and renewal Stan Dorn, Applying 21st-Century Eligibility and Enrollment Methods to National Health Care Reform, December 1, 2009, prepared by the Urban Institute for the Pharmaceutical Research and Manufacturers of America, http://www.urban.org/uploadedpdf/411985_national_health_care_reform.pdf http://www.urban.org/uploadedpdf/411985_national_health_care_reform.pdf Massachusetts enrollment Stan Dorn, Ian Hill, Sara Hogan, The Secrets of Massachusetts Success: Why 97 Percent of State Residents Have Health Coverage, Prepared by the Urban Institute for the Robert Wood Johnson Foundation, http://www.urban.org/publications/411987.htmlhttp://www.urban.org/publications/411987.html Louisiana renewal Tricia Brooks, The Louisiana Experience: Successful Steps to Improve Retention in Medicaid and SCHIP, February 2009, Georgetown University Center for Children and Families, http://ccf.georgetown.edu/index/cms-filesystem-action?file=postcards/the%20louisiana%20experience.pdfhttp://ccf.georgetown.edu/index/cms-filesystem-action?file=postcards/the%20louisiana%20experience.pdf Ruth Kennedy, Enrolling & Retaining Everyone Who is Eligible, December 1, 2009, prepared for the Alliance for Health Reform, http://www.allhealth.org/briefingmaterials/RuthKennedyedited-1661.ppt http://www.allhealth.org/briefingmaterials/RuthKennedyedited-1661.ppt Express Lane Eligibility Stan Dorn, Express Lane Eligibility and Beyond: How Automated Enrollment Can Help Eligible Children Receive Medicaid and CHIP, April 2009, prepared by the Urban Institute for the Robert Wood Johnson Foundation, http://www.urban.org/UploadedPDF/411879_eligible_children.pdfhttp://www.urban.org/UploadedPDF/411879_eligible_children.pdf National Academy for State Health Policy, New CHIPRA Opportunity: Express Lane Eligibility, May 2009 Webinar, http://www.maxenroll.org/resource/new-chipra-opportunity-express-lane-eligibility http://www.maxenroll.org/resource/new-chipra-opportunity-express-lane-eligibility