Retention Initiative Group Conference Call

June 11, 2008

J. Ruth KennedyLa. Dept of Health & Hospitals

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“A Rising Tide Lifts All Boats”

—John F. Kennedy

Improvements to SCHIP Renewal Process & Retention

Improvements to Medicaid Renewal Process & Retention

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Our Moment of Reckoning—Net Loss of > 6,000 Kids in November 1999

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”Houston, we’ve got a problem”

A “Hole in the Bucket” or Renewal Woes

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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

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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

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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 Method Implementation Date

Ex Parte for SSI or TANF Closure July, 2000

Ex Parte with Active Food Stamps

July, 2001

Telephone & Off Cycle November, 2003

Automatic Voice Response (AVR)

July, 2006

Internet December, 2007

Ex Parte without Active Food Stamps

January, 2008

Administrative for Low Risk Cases

July, 2008

“Paths” to Renewal for LA Children in May 08

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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

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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

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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

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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

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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!

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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 < $500Eligibility system data analysis indicates very lowlikelihood of closure due to income for cases withthese characteristics.

Administrative Renewals [Semantics Do Matter]

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Questions????

Telephone, AVR & Administrative Renewals

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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 e-mail to all

eligibility staff with commentary Critical for measuring improvement and

monitoring Correct caseworker coding is critical

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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, 1880-1944

Head, Bank of EnglandYikes!!

The Bottom Line — What it Means for Louisiana Kids!

Program Children Due for Renewal

Closed –Failure to

Locate/Complete Renewal

Procedural Closure

Percentage

LaCHIP 9,356 88 .94%

Medicaid 30,617 409 1.34%

Actual Totals for 5/08

39,973 497 1.24%

At 3/01 Procedural Closure Rate

8,526 21.33%

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

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“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!

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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

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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

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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

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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

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“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 ManagerLaPlace, 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

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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

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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

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“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

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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

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Ruth KennedyLaCHIP Director & Medicaid Deputy DirectorLouisiana Department of Health & HospitalsP.O. Box 91030 Baton Rouge, LA 70821-9030Telephone: 225 342 3032Fax: 225 342 9508E-Mail: rkennedy@dhh.la.gov www.lachip.org

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