2. 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

3. 2 Medicaid Eligibility in Louisiana: Administrative Factors to Consider Medicaid eligibility has been determined by employees of the state Medicaid agency since 92 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 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 Medicaid Central Office has direct line authority over the ~800 eligibility employees in local offices throughout the state

4. 3

5. 4 SCHIP in Louisiana was implemented as a Medicaid expansion beginning in 11/98 SCHIP in Louisiana was implemented as a Medicaid expansion beginning in 11/98 Seamless process for applicants—No differentiation between Medicaid & SCHIP Seamless process for applicants—No differentiation between Medicaid & SCHIP “Many of the ‘Right’ Things” “Many of the ‘Right’ Things” One Page Application Form One Page Application Form Mail In Applications Mail In Applications No Face-to-Face Interview Required No Face-to-Face Interview Required No Assets Test No Assets Test Twelve Months Continuous Eligibility for Children Twelve Months Continuous Eligibility for Children

6. 5 * How Many Ways Can You Count Children Enrolled? Enrolled or Recipients Enrolled or Recipients All “New” Children or Net Change in Children All “New” Children or Net Change in Children Title 19 Medicaid or Title 21 SCHIP or Combined Title 19 Medicaid or Title 21 SCHIP or Combined Calendar Month “Snapshot” or Unduplicated Total 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 If unduplicated total, for State Fiscal Year or Federal Fiscal Year or Calendar Year or Since the Program Began * With apologies to Robert Browning

7. 6 SCHIP (Title 21 Medicaid) Enrollment for Children Under Age 19—11/98 to Present 47 Consecutive Months With a Net Gain in Enrollment for Title 21!!!!!

8. 7 Medicaid (Title 19) Enrollment for Children Under Age 19

9. 8 Net Change in Monthly Enrollment of Children--Medicaid and SCHIP “Houston, we’ve got a problem” -6000 -4000 -2000 0 2000 4000 6000 8000 10000 12000 14000 D-98 M-99 J-99 S-99 Dec-99 Mar-00Jun-00 Sep-00 Dec-00 1-Mar 1-Jun 1-Sep 1-Dec 2-Mar 2-Jun 2-Sep

10. 9 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

11. 10 Data “Issues” Facing Louisiana Medicaid in 11/99 Medicaid management reports were created based on needs of AFDC program Medicaid management reports were created based on needs of AFDC program Renewal dispositions were reported at case level, rather than child level 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 Emphasis was on timely completing renewal and not letting the case “expire”; actual disposition was not relevant Closure reports captured all closures Closure reports captured all closures Previous mainframe software program did not have any additional “space” to add new fields 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 Competing priorities--system and/or programming staff shared with TANF/Support Enforcement/Food Stamp/Child Care Assistance Programs

12. 11 Data Prerequisites for Measuring & Targeting Retention Efforts Specific codes for procedural closure reasons Specific codes for procedural closure reasons Educate Medicaid Analysts in importance of selecting most appropriate code Educate Medicaid Analysts in importance of selecting most appropriate code Capture actual disposition of renewal (rather than if the renewal was “completed”) 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 Report variable needs to be the disposition of child rather than disposition of case

13. 12 A Watershed Event -- April 7, 2000 SMD Letter Clarification and very specific guidance issued by HCFA regarding ex parte redetermination requirements 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 States were directed to review policies, procedures and practices related to determination of continued eligibility for persons impacted by Welfare Reform Former TANF recipients Former TANF recipients 1931 Population—Families & Children 1931 Population—Families & Children 4913 Children Who Received SSI 8/22/96 But Are Ineligible Due to New Definition of Disability 4913 Children Who Received SSI 8/22/96 But Are Ineligible Due to New Definition of Disability

14. 13 Ex Parte Renewal Policy Developed and Implemented Major policy changes effective 7/1/00—three month moratorium on closures while policy was being written 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 Procedures for use in implementing the policy were established Use of SDX, Food Stamp, and TANF systems information Use of SDX, Food Stamp, and TANF systems information Manager training in new policy, procedures, and expectations for local office practices Manager training in new policy, procedures, and expectations for local office practices

15. 14 Another Watershed Event in Early Summer of 2000 June 9, 2000 National APHSA Meeting in Detroit, which focused on TANF/Medicaid de-linking 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 Presentations included one by Fred Elig, regarding Ohio’s reduction in verification requirements for Medicaid enrollment

16. 15 Training for Managers Regarding Change in Focus at (Then) HCFA From strong emphasis on quality control, error reduction, thorough case documentation... 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.... 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.

17. 16 Factors Contributing to Change in Focus & Priorities Universal health care debate in 1994 was a catalyst for recognizing the importance of health insurance and further research. 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. 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. Passage of State Children’s Health Insurance Program and problems in enrolling eligible children.

18. 17 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. “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

19. 18 Medicaid Verification Requirements, Circa May, 2000 Our Medicaid verification requirements were copied from AFDC verification requirements 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 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. QC error findings required corrective action implementation to avoid sanctions. These often involved additional information gathering and documentation requirements for case records.

20. 19 Result of 25 Year Focus on Quality Control and Case Validity

21. 20 Important Income Verification Issues Medicaid vs. TANF/Food Stamps TANF/Food Stamps Benefit level as well as eligibility is being established Benefit level as well as eligibility is being established Preciseness of income projection is always of extreme importance Preciseness of income projection is always of extreme importanceMedicaid For most programs, benefit level is not a factor, only eligibility 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 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

22. 21 Radical Changes in Verification Requirements Effective 7/2000 Allowed for self-declaration of citizenship, residence, unless questionable Allowed for self-declaration of citizenship, residence, unless questionable Social security cards not to be requested if number provided Social security cards not to be requested if number provided Other systems (Food Stamp, TANF) could be used to verify age 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 Reduced income verification period from 8 weeks to 4 weeks PLUS established the concept of “reasonable certainty” in income determinations

23. 22 Additional Focus on Retention During 2001 A “new name”—changed name of the process formerly known as “redetermination” to “renewal” New simplified Renewal Form New simplified Renewal Form Requested that Regions design and implement projects to improve renewal outcomes Requested that Regions design and implement projects to improve renewal outcomes “Best practices” shared “Best practices” shared Ex parte renewals for children with active Food Stamp cases Ex parte renewals for children with active Food Stamp cases 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”

24. 23 Ex Parte Eligibility Renewals for More Children Expanded ex parte renewal policy to apply to all children with active Food Stamp case effective 7/1/01. In essence, “adjunctive eligibility” 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 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 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 Over 25 % of all Title 19 renewals in October were completed without the family being required to complete & return a renewal form

25. 24 Telephone Follow-up When Renewal Form is Not Returned Policy changed to require an attempt to contact by telephone prior to closure, beginning 7/1/01 Policy changed to require an attempt to contact by telephone prior to closure, beginning 7/1/01 Local office examples of “customization” of policy Local office examples of “customization” of policy 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

26. 25 Local Office Involvement in Developing Retention Improvement Plans Participating in workgroup resulted in greater awareness of the problem (education/training) Participating in workgroup resulted in greater awareness of the problem (education/training) Front-line staff have unique insights and proposed excellent strategies Front-line staff have unique insights and proposed excellent strategies Ownership and buy-in was achieved 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

27. 26 Examples of Local Initiatives to Improve Retention & Enrollment Supervisory review of all procedural closures at renewal Supervisory review of all procedural closures at renewal Not requesting ANY verifications at renewal Not requesting ANY verifications at renewal Adding a “drop box” outside the building for after hours convenience to return renewal forms, verifications 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 Additional “reminders” e.g. fluorescent pink reminder flyer prior to advance notice of closure Enclosing another renewal form/SASE with advance notice of closure Enclosing another renewal form/SASE with advance notice of closure Using US Postal Return Service Using US Postal Return Service Telephone surveys of families who failed to return the renewal form Telephone surveys of families who failed to return the renewal form

28. 27 Incremental Changes in Reducing Verification Requirements Age Relationship April, 2002 Voluntary Child Support July, 2001 Citizenship Louisiana Residence July, 2000

29. 28 “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.” “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

30. 29 Some “Lessons Learned” Relative to Data Invariably, the data someone is requesting is the one item not available on an existing report 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 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 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 Too much information is problematic; to be useful, data needs to be in a easily interpreted, comprehensive, and concise format

31. 30 Conclusions from 6/00 “Who Moved the Cheese?” Training Remain Relevant They HAVE moved the cheese. They HAVE moved the cheese. The quicker you let go of old cheese, the sooner you can enjoy new 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! They keep moving the cheese so be ready to change quickly!

32. 31 Ongoing Evaluation of Policies, Procedures and Practices Some policies and procedures have unintended consequences, or in retrospect prove to be unnecessary; Some policies and procedures have unintended consequences, or in retrospect prove to be unnecessary; Example: policy to hold renewals and not close them for procedural reasons until deadline day for closures 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 “Best practices” need to be identified, documented and shared with other offices Good renewal outcomes by regions and offices deserve acknowledgement and recognition Good renewal outcomes by regions and offices deserve acknowledgement and recognition

33. 32 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