21st-century enrollment and retention

Families USA: Health Action 2010

January 28, 2010

Stan Dorn

The Urban Institute

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Overview What’s so special about the 21st-century? Examples

MassachusettsLouisianaExpress Lane Eligibility

Part I

What’s so special about the 21st

Century?

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Computers!

The government has lots of data about us

It’s 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?

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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

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What else is so special about the 21st century?

Behavioral economics, of course! Basic concept: human beings are not fully

rational

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Example #1: Retirement savings Percentage of eligible workers who participate in

tax-advantaged retirement accounts

33%

90%

Firms where new hires enroll in 401(k)only after completing a form

Firms where new hires go into 401(k)UNLESS they complete an opt-out form

Sources: Laibson (NBER), 2005.

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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.

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Why?

ConfusionDiscomfortCompeting prioritiesProcrastination

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A golden rule of behavioral economics:

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“Applications? We don’t need no stinkin’

applications!”

Part II

Examples:

Boston enrollment, Baton Rouge renewals, and

The Express Lane

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Boston: enrollment

Preliminary findings from a SHARE grant funded by the Robert Wood Johnson Foundation

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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

coverageo Exception for those unable to

afford it Health insurance exchange

offers multiple private plans

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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

enrollees—roughly 1/4th of all increased coverage

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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 applicant’s 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

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Baton Rouge: renewals

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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

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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

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The final example

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Express Lane Eligibility (ELE) New state option in Children’s 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

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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.

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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

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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 isn’t simple” (Ruth Kennedy, LaCHIP

Director) Persistence and creativity will be required

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Where to find more information about various topics? 21st-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

Massachusetts enrollmentStan 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.html

Louisiana renewalTricia 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.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

Express Lane EligibilityStan 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.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