Louisiana Medicaid EligibilityLouisiana Medicaid Eligibility

Improving Work Processes Improving Work Processes at the Local Levelat the Local Level

Supporting Families after Welfare Reform Learning Supporting Families after Welfare Reform Learning SessionSession

November 14, 2002November 14, 2002

J. Ruth Kennedy, Medicaid Deputy DirectorJ. Ruth Kennedy, Medicaid Deputy DirectorCarolyn R. Norman, Medicaid Area ManagerCarolyn R. Norman, Medicaid Area Manager

Louisiana Department of Health & HospitalsLouisiana Department of Health & Hospitals

22

Medicaid Eligibility in Medicaid Eligibility in Louisiana: Administrative Louisiana: Administrative

Factors to ConsiderFactors to Consider Medicaid eligibility has been determined by Medicaid eligibility has been determined by

employees of the state Medicaid agency since employees of the state Medicaid agency since 9292

Medicaid Analysts process Medicaid Analysts process onlyonly Medicaid and Medicaid and SCHIP cases—eligibility for TANF, Food Stamps, SCHIP cases—eligibility for TANF, Food Stamps, Child Care Assistance is handled by the Child Care Assistance is handled by the Department of Social ServicesDepartment of Social Services

Medicaid Central Office has Medicaid Central Office has direct line authoritydirect line authority over the ~800 eligibility employees in local over the ~800 eligibility employees in local offices throughout the stateoffices throughout the state

33

44

SCHIP in Louisiana was implemented as a SCHIP in Louisiana was implemented as a Medicaid expansion beginning in 11/98Medicaid expansion beginning in 11/98

SeamlessSeamless process for applicants—No process for applicants—No differentiation between Medicaid & SCHIPdifferentiation between Medicaid & SCHIP

““Many of the ‘Right’ Things”Many of the ‘Right’ Things” One Page Application Form One Page Application Form Mail In ApplicationsMail In Applications No Face-to-Face Interview RequiredNo Face-to-Face Interview Required No Assets TestNo Assets Test Twelve Months Continuous Eligibility for Twelve Months Continuous Eligibility for

ChildrenChildren

55

* * How Many Ways Can You How Many Ways Can You Count Children Enrolled?Count Children Enrolled?

EnrolledEnrolled oror Recipients Recipients All “New” Children All “New” Children oror Net Change in Net Change in

ChildrenChildren Title 19 Medicaid Title 19 Medicaid oror Title 21 SCHIP Title 21 SCHIP oror

CombinedCombined Calendar Month “Snapshot”Calendar Month “Snapshot” oror

Unduplicated Total Unduplicated Total If unduplicated total, for State Fiscal If unduplicated total, for State Fiscal

Year Year or or Federal Fiscal Year Federal Fiscal Year or or Calendar Calendar Year or Since the Program BeganYear or Since the Program Began

* With apologies to Robert Browning

66

SCHIP (Title 21 Medicaid) SCHIP (Title 21 Medicaid) Enrollment for Children Enrollment for Children Under Age 19—11/98 to Under Age 19—11/98 to

PresentPresent

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

N-98

J-99

M-99

M-99

J-99

S-99

N-99

Jan-00

Mar-0

0

May-00

Jul-0

0

Sep-00

Nov-00

1-Jan

1-M

ar

1-M

ay

1-Jul

1-Sep

1-N

ov

2-Jan

2-M

ar

2-M

ay

2-Jul

2-Sep

47 Consecutive Months With a Net Gain in Enrollment

for Title 21!!!!!

77

300,000

320,000

340,000

360,000

380,000

400,000

420,000

440,000

460,000

480,000

N-97

F-98

M-98

A-98

N-98

F-99

M-99

A-99

N-99

Feb

-00

May-00

Aug-00

Nov-00

1-Feb

1-May

1-Aug

1-Nov

2-Feb

2-May

2-Aug

Medicaid (Title 19) Enrollment Medicaid (Title 19) Enrollment for Children Under Age 19for Children Under Age 19

88

Net ChangeNet Change in Monthly Enrollment in Monthly Enrollment of Children--Medicaid and SCHIPof 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-0

0

Jun-00

Sep-00

Dec-00

1-M

ar

1-Jun

1-Sep

1-Dec

2-M

ar

2-Jun

2-Sep

99

Renewal Woes Renewal Woes A Hole in the BucketA 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

1010

Data “Issues” Facing Data “Issues” Facing Louisiana Medicaid in 11/99Louisiana Medicaid in 11/99

Medicaid management reports were created based Medicaid management reports were created based on needs of AFDC programon needs of AFDC program Renewal dispositions were reported at Renewal dispositions were reported at casecase level, rather level, rather

than than childchild level level Emphasis was on timely completing renewal and not Emphasis was on timely completing renewal and not

letting the case “expire”; letting the case “expire”; actual disposition was not actual disposition was not relevantrelevant

Closure reports captured Closure reports captured allall closures closures Previous mainframe software program did not have Previous mainframe software program did not have

any additional “space” to add new fieldsany additional “space” to add new fields Competing priorities--system and/or programming Competing priorities--system and/or programming

staff shared with TANF/Support Enforcement/Food staff shared with TANF/Support Enforcement/Food Stamp/Child Care Assistance ProgramsStamp/Child Care Assistance Programs

1111

Data Prerequisites for Data Prerequisites for Measuring & Targeting Measuring & Targeting

Retention EffortsRetention Efforts

Specific codes for procedural closure reasonsSpecific codes for procedural closure reasons Educate Medicaid Analysts in importance of Educate Medicaid Analysts in importance of

selecting most appropriate codeselecting most appropriate code Capture actual disposition of renewal (rather Capture actual disposition of renewal (rather

than if the renewal was “completed”)than if the renewal was “completed”) Report variable needs to be the disposition of Report variable needs to be the disposition of

childchild rather than disposition of rather than disposition of casecase

1212

A Watershed Event --A Watershed Event -- April 7, 2000 SMD Letter April 7, 2000 SMD Letter

Clarification and very specific Clarification and very specific guidance issued by HCFA regarding guidance issued by HCFA regarding ex ex parteparte redetermination requirements redetermination requirements

States were directed to review States were directed to review policiespolicies, , procedures procedures andand practices practices related to determination of continued related to determination of continued eligibility for persons impacted by eligibility for persons impacted by Welfare ReformWelfare Reform Former TANF recipients Former TANF recipients 1931 Population—Families & 1931 Population—Families &

ChildrenChildren 4913 Children Who Received SSI 4913 Children Who Received SSI

8/22/96 But Are Ineligible Due to 8/22/96 But Are Ineligible Due to New Definition of DisabilityNew Definition of Disability

1313

Ex ParteEx Parte Renewal Policy Renewal Policy Developed and ImplementedDeveloped and Implemented

Major Major policypolicy changes effective 7/1/00— changes effective 7/1/00—three month moratorium on closures while three month moratorium on closures while policy was being writtenpolicy was being written

ProceduresProcedures for use in implementing the for use in implementing the policy were establishedpolicy were established Use of SDX, Food Stamp, and TANF systems Use of SDX, Food Stamp, and TANF systems

informationinformation Manager training in new policy, procedures, Manager training in new policy, procedures,

and expectations for local office and expectations for local office practicespractices

1414

Another Watershed Event in Another Watershed Event in Early Summer of 2000Early Summer of 2000

June 9, 2000 National APHSA Meeting June 9, 2000 National APHSA Meeting in Detroit, which focused on in Detroit, which focused on TANF/Medicaid de-linkingTANF/Medicaid de-linking

Presentations included one by Fred Presentations included one by Fred Elig, regarding Ohio’s reduction in Elig, regarding Ohio’s reduction in verification requirements for verification requirements for MedicaidMedicaid enrollment enrollment

1515

Training for Managers Training for Managers Regarding Change in Focus at Regarding Change in Focus at

(Then) HCFA(Then) HCFA From strong emphasis on From strong emphasis on quality control, error reduction, quality control, error reduction, thorough case thorough case documentation . . .documentation . . .

. . . To removing barriers, . . . To removing barriers, making enrollment process making enrollment process “user friendly”, enrolling eligible “user friendly”, enrolling eligible children and families, assuring children and families, assuring loss of cash does not translate loss of cash does not translate to loss of Medicaid as well. to loss of Medicaid as well.

1616

Factors Contributing to Factors Contributing to Change in Focus & PrioritiesChange in Focus & Priorities

Universal health care debate in Universal health care debate in 1994 was a catalyst for 1994 was a catalyst for recognizing the importance of recognizing the importance of health insurance and further health insurance and further research.research.

Welfare reform de-linkage and Welfare reform de-linkage and resulting resulting unintendedunintended huge huge declines in Medicaid caseloadsdeclines in Medicaid caseloads—State by State review in fall —State by State review in fall of 1999.of 1999.

Passage of State Children’s Passage of State Children’s Health Insurance Program and Health Insurance Program and problems in enrolling eligible problems in enrolling eligible childrenchildren..

1717

Legacy of Onerous Verification Legacy of Onerous Verification Requirements in LouisianaRequirements in Louisiana

““She was one of those She was one of those “[welfare] oriented “[welfare] oriented workers" last year. I workers" last year. I had the hardest time had the hardest time with her with with her with application application simplification, because simplification, because she was one that "grew she was one that "grew up" making the clients up" making the clients verify everything but verify everything but the air in their tires.the air in their tires.

--Medicaid Analyst Supervisor--Medicaid Analyst Supervisor

1818

Medicaid Verification Medicaid Verification Requirements, Requirements, Circa Circa May, May,

20002000 Our Medicaid verification Our Medicaid verification

requirements were copied from requirements were copied from AFDCAFDC verification requirements verification requirements

Tough Tough sanctionssanctions for first 30 for first 30 years of Medicaid Program for years of Medicaid Program for exceeding 3% error tolerance exceeding 3% error tolerance levellevel

QC error findings required QC error findings required corrective actioncorrective action implementation to avoid implementation to avoid sanctions. These often involved sanctions. These often involved additional information additional information gathering and gathering and documentationdocumentation requirements for case records.requirements for case records.

1919

Result of 25 Year Focus on Result of 25 Year Focus on Quality Control and Case Quality Control and Case

ValidityValidity

2020

Important Income Important Income Verification Issues Medicaid Verification Issues Medicaid

vs. TANF/Food Stampsvs. TANF/Food StampsTANF/Food StampsTANF/Food Stamps

Benefit level as well as Benefit level as well as eligibility is being eligibility is being establishedestablished

PrecisenessPreciseness of income of income projection is always of projection is always of extreme importanceextreme importance

MedicaidMedicaid For most programs, For most programs,

benefit levelbenefit level is not a is not a factor, only eligibilityfactor, only eligibility

If income is If income is clearly clearly belowbelow the maximum the maximum and eligibility is and eligibility is established, exact established, exact amount is not criticalamount is not critical

Exceptions are Long Term Care, Exceptions are Long Term Care, and Spend Down Medically Needyand Spend Down Medically Needy

2121

Radical Changes in Radical Changes in Verification Requirements Verification Requirements

Effective 7/2000Effective 7/2000 Allowed for self-declaration of citizenship, Allowed for self-declaration of citizenship,

residence, unless questionableresidence, unless questionable Social security cards not to be requested if Social security cards not to be requested if

number providednumber provided Other systems (Food Stamp, TANF) could be Other systems (Food Stamp, TANF) could be

used to verify ageused to verify age Reduced income verification period from 8 Reduced income verification period from 8

weeks to 4 weeks PLUS established the weeks to 4 weeks PLUS established the concept of “concept of “reasonable certaintyreasonable certainty” in income ” in income determinationsdeterminations

2222

Additional Focus on Retention Additional Focus on Retention During 2001During 2001

A “new name”—changed name of the process formerly A “new name”—changed name of the process formerly known as “redetermination” to “renewal”known as “redetermination” to “renewal”

New simplified Renewal Form New simplified Renewal Form Requested that Regions design and implement projects to Requested that Regions design and implement projects to

improve renewal outcomesimprove renewal outcomes ““Best practices” sharedBest practices” shared Ex parteEx parte renewals for children with active Food Stamp cases renewals for children with active Food Stamp cases

Retention was a major issue at Retention was a major issue at February 2001 February 2001 Covering KidsCovering Kids regional regional meeting in Arlington, VA we meeting in Arlington, VA we attended. It was the catalyst for attended. It was the catalyst for additional changes in 2001”additional changes in 2001”

2323

Ex ParteEx Parte Eligibility Renewals Eligibility Renewals for More Childrenfor More Children

Expanded Expanded ex parteex parte renewal policy to apply to renewal policy to apply to all children with active Food Stamp case all children with active Food Stamp case effective 7/1/01. In essence, “adjunctive effective 7/1/01. In essence, “adjunctive eligibility”eligibility”

Notice developed to advise families that we Notice developed to advise families that we have established their continued eligibility for have established their continued eligibility for 12 more months12 more months

Established “new” renewal code (Code 11) to Established “new” renewal code (Code 11) to identify identify ex parteex parte renewals renewals

Over 25 % of all Title 19 renewals in October Over 25 % of all Title 19 renewals in October were completed without the family being were completed without the family being required to complete & return a renewal formrequired to complete & return a renewal form

2424

Telephone Follow-up When Telephone Follow-up When Renewal Form is Not ReturnedRenewal Form is Not Returned

Policy changed to Policy changed to require an attempt to require an attempt to contact by telephone contact by telephone prior to closure, prior to closure, beginning 7/1/01beginning 7/1/01

Local office examples of Local office examples of “customization” of policy“customization” of policy At least one call should be At least one call should be

before 7:00 A.M. or after before 7:00 A.M. or after 5:00 P.M.5:00 P.M.

Confirm current mailing Confirm current mailing address and phone address and phone number at point of ANY number at point of ANY contact with the contact with the householdhousehold

2525

Local Office Involvement in Local Office Involvement in Developing Retention Developing Retention

Improvement PlansImprovement Plans Participating in workgroup resulted in Participating in workgroup resulted in

greater awareness of the problem greater awareness of the problem (education/training)(education/training)

Front-line staff have unique insights and Front-line staff have unique insights and proposed excellent strategiesproposed excellent strategies

Ownership and buy-in was achievedOwnership and buy-in was achieved““I think one of the highlights staff enjoyed I think one of the highlights staff enjoyed was being able to come up with a renewal was being able to come up with a renewal plan, and then watch their ideas at work”plan, and then watch their ideas at work”

-- Debbie Falgout, Medicaid Analyst Supervisor-- Debbie Falgout, Medicaid Analyst SupervisorThibodaux, LouisianaThibodaux, Louisiana

2626

Examples of Examples of LocalLocal Initiatives to Initiatives to Improve Retention & Improve Retention &

EnrollmentEnrollment Supervisory review of all procedural closures at Supervisory review of all procedural closures at

renewal renewal Not requesting ANY verifications at renewal Not requesting ANY verifications at renewal Adding a “drop box” outside the building for after Adding a “drop box” outside the building for after

hours convenience to return renewal forms, hours convenience to return renewal forms, verificationsverifications

Additional “reminders” Additional “reminders” e.g.e.g. fluorescent pink fluorescent pink reminder flyer prior to advance notice of closurereminder flyer prior to advance notice of closure

Enclosing another renewal form/SASE with advance Enclosing another renewal form/SASE with advance notice of closurenotice of closure

Using US Postal Return ServiceUsing US Postal Return Service Telephone surveys of families who failed to return Telephone surveys of families who failed to return

the renewal formthe renewal form

2727

Incremental Changes in Incremental Changes in Reducing Verification Reducing Verification

RequirementsRequirements

AgeRelationship

April, 2002

Voluntary Child SupportJuly, 2001

CitizenshipLouisiana Residence

July, 2000

2828

““New Thinking” in Local New Thinking” in Local OfficesOffices

““What is making a difference is staff has What is making a difference is staff has changed their changed their way of thinkingway of thinking and they do and they do bend over backwards to helpbend over backwards to help the recipient. the recipient. The mindset is that the applicant or The mindset is that the applicant or recipient is our number one priority. . . .the recipient is our number one priority. . . .the Analyst continues to extend time when the Analyst continues to extend time when the recipient states he or she needs more time recipient states he or she needs more time to get the information in. The Analyst will to get the information in. The Analyst will help the recipient to gather information or help the recipient to gather information or documentation whenever possible.”documentation whenever possible.”

--Margo Joseph, Medicaid Area Manager--Margo Joseph, Medicaid Area ManagerLaPlace, LouisianaLaPlace, Louisiana

2929

Some “Lessons Learned” Some “Lessons Learned” Relative to DataRelative to Data

Invariably, the data someone is requesting is Invariably, the data someone is requesting is the the oneone item not available on an existing report item not available on an existing report

ValidityValidity of data is very much influenced by end of data is very much influenced by end users—education regarding how data will be users—education regarding how data will be used and the need for accuracy is used and the need for accuracy is criticalcritical

Refinement of data collection and back end Refinement of data collection and back end reporting is a reporting is a fluidfluid processprocess—needs change, new —needs change, new questions need answersquestions need answers

Too muchToo much information is problematic; to be information is problematic; to be useful, data needs to be in a easily interpreted, useful, data needs to be in a easily interpreted, comprehensive, and concise formatcomprehensive, and concise format

3030

Conclusions from 6/00 “Who Moved Conclusions from 6/00 “Who Moved the Cheese?” Training Remain the Cheese?” Training Remain

RelevantRelevant They HAVE moved They HAVE moved

the cheese.the cheese. The quicker you let The quicker you let

go of old cheese, the go of old cheese, the sooner you can enjoy sooner you can enjoy new cheese.new cheese.

They keep moving They keep moving the cheese so be the cheese so be ready to change ready to change quickly!quickly!

3131

OngoingOngoing Evaluation of Policies, Evaluation of Policies, Procedures and PracticesProcedures and Practices

Some policies and procedures have Some policies and procedures have unintended consequences, or in unintended consequences, or in retrospect prove to be unnecessary;retrospect prove to be unnecessary; Example: policy to hold renewals and not close Example: policy to hold renewals and not close

them for procedural reasons until deadline day them for procedural reasons until deadline day for closuresfor closures

““Best practices” need to be identified, Best practices” need to be identified, documented and shared with other officesdocumented and shared with other offices

Good renewal outcomes by regions and Good renewal outcomes by regions and offices deserve acknowledgement and offices deserve acknowledgement and recognitionrecognition

3232

For Additional Information on For Additional Information on Louisiana Medicaid Local Louisiana Medicaid Local

Processes Processes Ruth KennedyRuth KennedyMedicaid Deputy DirectorMedicaid Deputy DirectorLouisiana Department of Health & Louisiana Department of Health &

HospitalsHospitalsP.O. Box 91030 P.O. Box 91030 Baton Rouge, LA 70821-9030Baton Rouge, LA 70821-9030Telephone: 225 342 3032Telephone: 225 342 3032Fax: 225 342 9508Fax: 225 342 9508E-MailE-Mail: : rkennedy @ dhh.state.la.usrkennedy @ dhh.state.la.us

Carolyn R. NormanCarolyn R. NormanMedicaid Area ManagerMedicaid Area ManagerTangipahoa Parish Medicaid OfficeTangipahoa Parish Medicaid Office121 Robin Hood Drive121 Robin Hood DriveHammond, LA 70403Hammond, LA 70403Telephone: 985 543 4217Telephone: 985 543 4217Fax: 985 543-4221Fax: 985 543-4221E-Mail: E-Mail: cnorman @ dhh.state.la.uscnorman @ dhh.state.la.us