Wednesday, 3 September 2003 Application Simplification Workgroup Present: Cassandra Stewart, Jeffrey Young, Liane Hiramoto, Mary Rydell, Eiko Cusick, Barbara Luksch, Lee-Ann Brewer (conference call), and Lillian Koller Next meeting: 22 September 2003 at 2:00 PM (topic: passive renewals) The purpose of the meeting was to review field test results for the children and pregnant women application (Form 1108) and prepare for publication. 1. Mahalo Barbara thanked the group for their work on form 1108! 2. Field Test Results Liane presented quantitative details from the 58 applications sent to Med-QUEST's Kauai and Oahu offices. a. Information from Applicants and Health Care Providers (74 completed questionnaires). * Many previous applicants found it easier or as easy to complete as the current application (Form 1100). * 80% of new applicants considered it easy to complete. * 95% of responses stated the "Common Questions and Answers" page was helpful. * Most were able to understand the "Rights and Responsibilities" page. * Those who wrote that the application was easy to understand and complete stated these reasons: simple and direct questions, easy to complete, had less to complete, checkboxes, and large print. * Several suggested the application more clearly state who should be included on the application. b. Information from Med-QUEST Eligibility Staff (28 completed questionnaires) * Most sections were sufficiently completed except Question 2. * 71% of responses stated the "Common Questions and Answers" page was helpful. * Most applicants removed and retained the "Rights and Responsibilities" page. * 64% responded that non-pregnant household members used the test application to apply. * 46% stated the test application assisted in processing and 50% said it did not assist in processing. * When asked what changes they recommended on the test application, 43% said eliminate it and 11% suggested better identifying the verification of pregnancy question. 3. Other Comments a. Barbara quoted two responses from Hawaii Covering Kids Local Project outreach workers: I really like the children and pregnant women application. It is much easier since questions not pertaining to them were taken out. The informational pages are very helpful for people who have never applied to Med-QUEST before. Tell your workgroup they did a good job! (Michelle) I want to say that this app is the best! I completed about 15-20 and each customer was happy and less stressed about the form. At one point or another, they used the blue application and that was just too much. The buff form isn't so bad, but eliminating the absent parent question and asking less questions on the pink form made the customers feel good about applying. For whatever reason, most couples don't last and when they seek health insurance for their child that is all they want, so this is indeed a great application form! (Charlette) b. Cassandra explained that overall the Oahu eligibility workers responded favorably to the children and pregnant women application but it will not expedite their internal processing. However, they understand it may make it easier for the customer to apply. c. Liane would like to see one application with different colored pages for different groups. Buff pages would have generic questions, pink pages would pertain to children and pregnant women, and blue pages would have all other questions. 4. Tweaks * Question 2A must stand out. It was suggested to put a bold box around it. * Question 5 can be confusing to parents. They are offered employer-sponsored health insurance for their children, but must pay for the premium. We will reword it to state: ".has an employed person been offered health insurance by the employer for herself or himself?" * Question 6: Lee-Ann, Liane, and Lillian agreed to add this line: "If I intentionally make false statements on this application, I may be prosecuted under Hawaii Revised Statutes 710-1063." * Page 6: This will be a tear-off sheet at the back of the application. Since page six is returned to Med-QUEST, Barbara suggested writing the Bilingual or Sign Interpreter Services information in the required languages (currently form 9000). * Page 7 (Rights and Responsibilities): we will rewrite the citizenship section and update the last line in EPSDT (refer to 07/01/03 minutes), and delete "if requested ahead of time" for bilingual, sign interpreter, or other accommodations. 5. Procedure When a Customer Requests an Application Cassandra field-tested answering calls requesting an application. The following questions could determine which application to send: a. Do you need health insurance for children only? b. Do you need health insurance for a pregnant woman only? c. Does an adult who is not pregnant need health insurance? If the answer is yes to C, send the buff application. If the answer is yes to A and/or B, send the pink application. If the caller is confused or doesn't know, send both applications. Another approach is to ask "Who in your household needs health insurance?" If it is children and/or pregnant women only, send the pink form but if a non-pregnant adult is mentioned send the buff form. 6. Next Steps Med-QUEST will get printing bids. After it is printed, DHS will host a news conference to announce its launch. Barbara, Eiko, and Po Kwan Wong (Healthy Child Care Hawaii Project) will distribute information packets with children and pregnant women applications to physicians and child care centers statewide. Monday, 22 September 2003 Renewal Simplification Workgroup Present: Noe Foster, Pearl Tsuji, Jeffrey Young, Cassandra Stewart, Susan Chung, Maile Shimabukuro, Aileen Hiramatsu, James Lum, Barbara Luksch, and Lillian Koller Next meeting: 1 October 2003 at 2:30 PM (topics: cover letters sent by Med-QUEST offices) The purpose of the meeting was to discuss passive renewals. Our outcome is that all eligible children and youth enrolled in QUEST and Medicaid will maintain their benefits without interruption. 1. Health Plan Churning Data (July 2002-June 2003) We requested data to monitor our success after we implement a passive renewal system. The three QUEST plans calculated approximate data on churning: a. AlohaCare: approximately 6,000 reenrolled children who had their health insurance interrupted during the plan year. The data were pulled from Med-QUEST's active and disenrollment codes. b. HMSA: approximately 12,000 children and youth--up to 20 years old--were disenrolled and reenrolled. c. Kaiser: approximately 4,500 children reenrolled who were previously in Kaiser Permanente QUEST. They were at some time in the program although not necessarily within the past year. Susan suggested the health plans review criteria used to determine the data because children who are terminated from one program could immediately be placed in another one. Noe explained we requested data that are currently available to the health plans to help the workgroup develop a baseline for measuring our progress. 2. Other States * Florida, Georgia, Nevada, and Utah use passive renewals for children. Barbara distributed sample passive renewal forms from Florida and Nevada. * South Carolina's passive renewal information was shared at previous meetings. According to their Department of Health and Human Services, the state stopped its passive renewal system to presumably save money in their Medicaid budget. However, it is estimated that eligibility worker and clerk time required to disenroll and reenroll a child is more than the few months' capitation money saved by cutting off benefits. Furthermore, it can compromise the child's health. * Idaho's self-declaration error rates, as reported at the March 2001 Covering Kids West Regional meeting, were 0.5% wrongly approved and 3% wrongly denied. This is consistent with other states implementing self-declaration that report less than 2% error rates. 3. Med-QUEST Data * We requested updated data on cases closed per month to monitor our success after we implement a passive renewal system. Med-QUEST is currently refining its criteria to accurately determine the number. For example, they don't want to include children and youth who moved from regular QUEST to the CHIP expansion. * The current error rate for QUEST and Medicaid Fee-for-Service is 4.5% for the period ending September 2002. Causes that cannot be controlled are the number of applications received and number of workers. Reports are done semiannually and the target is 3%. * Med-QUEST is researching data on the number of cases: children only, adults only, children and adults. 4. Med-QUEST Concerns Regarding Passive Renewals a. How It Will Affect BESSD This will be discussed at a future meeting. b. Signature Changes The Policy and Program Development Office (PPDO) is in favor of a preprinted form but not passive renewals. They would like a signed form returned to ensure the customer received it and wants to continue her/his health insurance. We discussed that CMS does not require a signature if there are no household changes because the original signature is on file. Lillian explained there is a perceived notion that current application and renewal processes discriminate against those who are eligible for benefits, therefore it is important to implement changes that dispel this impression. Furthermore, it is cost effective to keep eligible customers enrolled and reduce error rates by spending eligibility worker time on random sample follow-up using SWICA (State Wage Information and Collection Agency) and other reports. c. Who It Applies To PPDO proposed the process apply to families with children. The current reapplication process would continue for individuals and families without children. d. Random Sampling This will ensure integrity is maintained for the health insurance programs. PPDO proposed the eligibility offices conduct random sampling, however Lillian suggested perhaps Management Services Office/Quality Control do the sampling. Criteria will be discussed at the next meeting. e. HAWI Support Med-QUEST's computer system should generate preprinted renewal forms for families with children as well as individuals and families without children to reduce staff workloads for ongoing cases. f. Field Test We could implement a field test for six months and review the results. Wednesday, 1 October 2003 Application Simplification Workgroup Present: Paul Higa, Ann G. Tam Sing, Cassandra Stewart, Barbara Luksch, and Lillian Koller Next meeting: 23 October 2003 at 1:30 PM (topic: passive renewals) The purpose of the meeting was to review forms that accompany Med-QUEST's application. 1. Cover Letter and Other Forms * Lillian explained that individualized handouts on different islands can be helpful, however when it comes to Med-QUEST eligibility information and processes, there must be one uniform voice. Therefore, she stated from now on there would be no individual Med-QUEST cover letters and no extraneous handouts published by different offices. * If Med-QUEST Eligibility Branch wants to produce a universal cover letter, the workgroup can glean important details from current editions and draft a version for testing. * The "Question and Answer" page on the children and pregnant women application (1108) was rated very high when field-tested, therefore it will be an extra page at the back of the application. Application form 1100 should have common questions and answers for non-pregnant adults added to the list. * Paul commended the workgroup for writing some elements of the application packet in the application form's "Rights and Responsibilities" (e.g., applicant's right to hearing, applicant's rights and obligations) thereby reducing the number of forms. We decided that since form 1108 will have forms 9000 and 1153 as part of the application, it will be distributed without other forms attached. Form 1100 (buff application) will have 1109 (temporarily until the application has information on self-declaration of pregnancy), 1153, and 9000 attached. * It was suggested that Barbara contact Yvonne Tanaka, Acting Compliance Officer for DHS Office of Civil Rights on wording to condense "Bilingual and Sign Interpreter Services" information. 2. Self-Declaration of Pregnancy * Barbara shared recent emails that explain CMS' rule allowing self-declaration of pregnancy. The woman must declare the pregnancy was confirmed either by a health care provider or home pregnancy test. * Paul explained that Med-QUEST's current procedures, which require written verification within 30 days of submitting an application, were to maintain program integrity. Angie stated this is double effort for already overloaded eligibility workers who must work the initial application and if verification is not received, work it a second time as a non-pregnant adult applying for health insurance. * Paul will review the information and get a response to Angie by Wednesday. 3. Health Insurance Portability and Accountability Act (HIPAA) and Authorized Representative * Current Med-QUEST rules allow only disclosure to individuals and not organizations. This is a serious problem for customers that use agencies to assist with their applications because if the individual (e.g., outreach worker, outstationed eligibility worker, community assistant, etc.) goes on vacation or leaves employment the agency cannot follow-up on the application. * Barbara attended a recent HIPAA workshop. The national presenter explained that 45 Section 164.508 (c) of HIPAA allows a category to be named person(s) or class of persons (e.g., organization). She also explained allowing a person rather than an organization to be designated is a potential problem for Med-QUEST because if that person leaves employment, she/he can still call Med-QUEST about a case. * Paul explained that if a state law is more stringent than HIPAA, Med-QUEST must follow the state law. In this situation, only allowing an individual to be an authorized representative is a Hawai'i Administrative Rule based on the authority Hawai'i Revised Statutes 346-10 gives DHS to promulgate rules regarding confidentiality. Thursday, 23 October 2003 Renewal Simplification Workgroup Present: Cassandra Stewart, Pearl Tsuji, Lillian Koller, Noe Foster, Barbara Luksch, Susan Chung, Ben Fong, Maile Aquino, Diane Taira (conference call), and Jeffrey Young. Next meeting: 4 December 2003 at 9:00 AM (topic: passive renewals) 1. Covering Kids & Families Process Improvement Collaborative Due to recent strides with Med-QUEST simplification strategies, Hawai'i is one of fifteen states selected to participate in this initiative. Our team has two Med-QUEST representatives (Alan Takahashi and Jeffrey Young), one local project representative (Stephany Vaioleti), and the Hawaii Covering Kids project director (Barbara Luksch). The collaborative's overall goal is to accelerate the process of maximizing efficient and effective enrollment and renewal processes for eligible adults and children in Medicaid and CHIP. We look forward to this new thirteen-month initiative and are eager to learn from technical expertise provided by the national collaborative leadership and other states. 2. Med-QUEST Data a. Number of Cases Pearl distributed a chart that shows there are 98,717 cases including 18,853 children only, 52,541 adults only, and 27,323 adults and children. The data was run on 09/23/03. b. Number of Cases Closed We requested statewide data on cases with at least one child. Pearl explained that May 2001-February 2002 data submitted to the workgroup did not exclude cases that moved from one program to another (e.g., from regular QUEST to CHIP, from QUEST to Medicaid Fee-for-Service, etc.), therefore the 1,437 average per month was an over count. Data from October 2002-July 2003 with refined criteria showed an average of 42 cases closed per month. The workgroup discussed the data: * There was concern from some members that the data are undercounts. Noe feels the October 2002-July 2003 statewide data noting 42 cases closed per month with at least one child seems unusually low. Also, the reason "Whereabouts Unknown" dropped from an average of 67 per month to 3. * Interviews are not required, however one may be requested by the customer or eligibility worker, therefore approximately 2 cases are closed per month due to "Fail to Keep Interview." * "Eligibility Requirement Not Met" could be a catchall code, however Pearl will send a memo requesting eligibility workers input more specific reasons in the future (e.g., income, residency, etc.). 3. Hawaii Administrative Rules (HAR) Med-QUEST must consolidate, rewrite, and update their HAR in 2004. The workgroup requested that it be a collaborative process and Med-QUEST's Policy and Program Development Office (PPDO) review drafts with people implementing the rules, including eligibility branch supervisors, community and state organizations, as well as the Centers for Medicare and Medicaid Services (CMS). Lillian explained it is less time consuming and more cost effective long-term if PPDO work with stakeholders prior to a public hearing and she will issue a memo requesting a collaborative process. Pearl explained that language is drafted to include a sunset date when the implemented law provides such a date (e.g., the law that gave the Governor certain powers after 11 September 2001). She was not familiar with including a sunset date for a temporary rule and suggested we consult with the Attorney General's office. Lillian and Diane discussed that if a procedure does not adversely impact customers, it can be implemented without changing the corresponding rule. Lillian requested a letter from the Attorney General 's office regarding this issue. 4. Passive Renewals: Georgia and Utah Barbara spoke with two more states implementing passive renewals: * Utah has used a preprinted form for three years and started passive renewals in June 2003 for its Children's Health Insurance Program (CHIP). Overall it has had a positive impact by decreasing their staff's workload due to less paperwork and telephone calls. They do monthly random sample follow-up by calling customers and reviewing information with them, employer checks through signed release forms, and interface with Utah's new hire registry. The only problem is that some eligibility workers don't like the system because they think people won't tell the truth. * Georgia also uses passive renewals in its CHIP. A parent can call to report changes by telephone and random sample follow-up is done through Department of Labor systems checks and interface with immigration. The only problem is that some eligibility workers feel they should guard the state, however others believe that getting eligible kids covered is ultimately the most important and therefore like the passive renewal system. 5. Preprinted Forms: Samples from Other States Samples from South Carolina, Georgia, Nevada, Utah, Florida, Montana, Arizona, Washington, Iowa, Michigan, Nebraska, and California were distributed. We also perused form 1311 titled "Monthly Eligibility Report Form" (MERF) used by the Department of Human Services' (DHS) Benefit, Employment, and Support Services Division. 6. Implementing Passive Renewals in Hawaii * Ben from DHS' Management Services Office explained that their researchers could determine a formula for valid random sampling for ongoing eligibility workers to implement. Jeffrey will follow-up with him. * Jeffrey estimated that passive renewals would save his unit approximately 25 hours/month/worker that could be devoted to more quality work on Income and Eligibility Verification System (IEVS) reports. * Currently, renewals are conducted annually. Reapplication forms are sent out during the 11th month and due in the 12th month. The form and verifications must be returned to Med-QUEST within 10 days of the mailing date. * We decided not to wait until all passive renewal letters could be automated but move forward with implementation specific to populations (children only cases followed by children and adult cases). * The workgroup does not want Hawai'i's passive renewal form to resemble an application or reapplication. Barbara will format a draft to disseminate to the group. Categories should include Household Members, Did Anyone Move In or Out, Address, Telephone Number, Income and Who Receives It, Assets and Owners' Names (for adult coverage), Health Insurance Information, Child Care Expenses, Accident in the Last Year, and Signature Line for Changes.