Thursday, 3 June 2004 Renewal Simplification Workgroup Present: Maile Aquino, Andreas Cravalho, Noe Foster, Karen Davenport, Laura Heller, Nicole Ravenell, Rochelle Sparko, Cynthia Goto, Cassandra Stewart, Lillian Koller, Mary Rydell, Alan Takahashi, Michelle Malufau, Susan Chung, Jeffrey Young, Barbara Luksch, Michelle Danley, and Kookie Moon-Ng Next meeting: TBA 1. Final Report of Live Test in Oahu Ongoing Unit III a. Overall Med-QUEST’s customers like the new forms. b. The return rates were: passive renewals 20% and regular renewals 40%. There is concern that the latter number is low and we must increase the return rate to decrease churning. c. The closure rate for April’s regular renewals was 46%. d. Statewide implementation began 1 June 2004. 2. Increasing Return Rate for Regular Renewals a. Eligibility workers should exhaust all possible ways to contact the customer before closing the case and we discussed the following: * A second notice (Form M600) is mailed to a customer prior to closing the case and it often prompts the recipient to respond. The workgroup will review this notice at its next meeting. * The procedures for mail returned with a forwarding address--outlined at our 8 April 2004 meeting--are: If the forwarding address is outside Hawaii: close the case. If the forwarding address is in Hawaii or there is no forwarding address: call the customer. Call at least three times at different hours throughout a one-week period and leave a minimum of two voicemail messages. If the telephone number in the case file is no longer in service, call telephone assistance to ask for a new number. * For mail returned with no forwarding address, call or email the customer. b. It was suggested that Med-QUEST’s applications read “Best Phone Number to Call” instead of “Daytime Telephone Number” because many people prefer using cellular telephones instead of landlines. Barbara will follow-up with the Application Simplification Workgroup. c. Involve outreach workers (see #5) and health plans (see #6). 3. Random Sample Follow-Up a. Forty-four cases were identified by Quality Improvement Control to test random sample review of passive renewal cases for O‘ahu Ongoing Unit III. Jeffrey drafted procedures that will be reviewed by the workgroup prior to statewide implementation. If the customer cannot be reached by telephone after three attempts, Form M011 will be mailed requesting the customer call the local Med-QUEST office for an interview. b. Following the test, 492 cases per year statewide will be selected for review. 4. Community Sessions on New Renewal Processes a. The meetings included: * Outstationed Eligibility Workers’ Meetings in April 2004: Med-QUEST supervisors from Hilo, Kailua-Kona, Oahu, Kauai, and Maui met with their respective groups. * Malama i na Keiki 5 on 30 April 2004: briefing for 102 community workers. * Hawaii Covering Kids State Coalition Meeting on 20 May 2004. b. Med-QUEST’s videoconference session for the Neighbor Islands will be 1 July 2004. 5. Postcard Renewal Reminders The Hawai‘i Covering Kids Kahuku Local Project will field-test mailing reminders to their customers prior to Med-QUEST’s renewal forms arriving. Results will be discussed at the next workgroup meeting with possible expansion to all outstationed eligibility workers throughout Hawaii. 6. QUEST Plans Helping with Renewals We discussed methods to involve QUEST plans in notifying their participants about passive and regular renewals. Ideas included: * Print information in regular publications. AlohaCare published details on passive renewals in their Spring 2004 provider’s newsletter and copies will be shared with Kaiser and HMSA. * Have renewal dates listed in the plans’ databases so they can send reminder notices. Kookie will verify if this data is available to include with other information transmitted to the plans. * Hawaii Covering Kids contact physician groups representing pediatricians, family physicians, and obstetricians and gynecologists to mail information on passive renewals to their members. 7. Using Email to Interact with Customers Barbara explained she is still trying to talk with James Lum, Hawaii State Department of Human Services Systems Officer on this topic. 8. New Drafts for Renewal Forms Samples for passive renewal draft #15 and regular renewal draft #6 were distributed. Workgroup members will send their comments to Barbara by 15 June 2004. 9. Process Improvement Collaborative: Centers for Medicare & Medicaid Services Answers to Questions a. For our state's renewal process, we want to implement ex parte reviews for customers who are chosen for random sample follow-up. There is concern that databases available to our Medicaid eligibility workers are three to twelve months old. Is there leeway for the age of IEVS reports that we use? Under the Federal regulations at 42 CFR 435.952 that govern the Income and Eligibility Verification System (IEVS), the state agency must review and compare against the case file all information received through IEVS to determine whether it affects the applicant's or recipient's eligibility or amount of medical assistance payment. The agency also must independently verify the information if required by 42 CFR 435.955 or if determined appropriate by agency experience. However, with respect to recipients, the state may target separately for each data source the information items that are most likely to be most productive in identifying and preventing ineligibility and incorrect payments. An agency that wishes to exclude categories of information items must submit for the Secretary's approval a follow-up plan describing the categories that it proposes to exclude. For each category, the agency must a reasonable justification that follow-up is not cost-effective. But now that I have provided these IEVS requirements, let me say that if you are looking for guidelines for using information to conduct ex parte reviews, please consult pages 5-6 of our April 7 State Medicaid Director letter, which can be found online at http://www.cms.hhs.gov/states/letters/smd40700.asp. You will find guidance as to sources of information to use while making the redetermination, which you can later verify (after you've made the redetermination) using the IEVS system. b. When a family reports changes to their existing case information, does CMS require a signed form accompany any information? Change examples include: request to stop Medicaid benefits, name, address, telephone number, email, move in, move out, assets, income, accident in the past year, and sell/trade/giveaway assets or property. If an individual is added to a case, the state shall require a declaration in writing stating whether the individual is a citizen or national of the United States or that the individual is in a satisfactory immigration status. Otherwise, I cannot think of an instance in which CMS would require that a report of a change in circumstance be accompanied by a signature. Please note that, per Federal regulations, a case record must include facts essential to the determination of initial and continuing eligibility. So, states should be sure to annotate case files as necessary when they learn of changes in circumstances that might affect eligibility. c. Can a state send mail to a Medicaid recipient using a forwarding address provided by the United States Postal Service? Yes. A state can accept a forwarding address for a recipient if it considers that address to be accurate. Given that the United States Postal Service is a federal government agency which requires that address change requests be submitted under penalty of perjury, a state can reasonably consider a forwarding address provided by the U. S. Postal Service to be accurate. 10. Other Information Noe explained that some physicians who were not open to patients enrolled in QUEST due to churning problems are excited about the new passive renewal process for cases with children. This could encourage more health care providers to participate in QUEST. Wednesday, 23 June 2004 Process Improvement Collaborative Present: Jeffrey Young, Alan Takahashi, Stephany Vaioleti, and Barbara Luksch Next meeting: 23 July 2004 at 1:30 PM 1. Returned Mail Barbara spoke with Kookie Moon-Ng at Med-QUEST’s Policy and Program Development Office. The Health Insurance Portability and Accountability Act (HIPAA) is silent on returned mail and the Centers for Medicare & Medicaid Services (CMS) allows states to forward mail (see information from number 9c in the Renewal Simplification Workgroup minutes from the 06/03/04 meeting). Therefore, the Hawaii State Department of Human Services (DHS) will change its current policy. 2. Samples of Completed Applications Posted at Med-QUEST Offices Participants at Malama i na Keiki 4 on 6 June 2003 suggested Med-QUEST post completed applications in its offices to visually help visitors. Jeffrey will get the samples of 1100 (buff) and 1108 (pink) to Barbara at the next meeting and she will laminate them. Alan will research if the Honolulu office’s landlord (Castle & Cooke) will allow this type of wall hanging. This idea could eventually expand to the Neighbor Island offices. 3. Random Sample Review for Passive Renewals Jeffrey reported that some eligibility workers really like the process and some do not. They successfully contacted about 70% of the families selected for reviews. Half had no changes to report while half had some changes but the children were still eligible. The eligibility workers could not reach 30% via telephone (e.g., disconnected, keeps ringing, left three messages but no response) so form M1011 was sent with a 10-day deadline to respond. It is a general correspondence letter asking the customer to please contact the worker for an interview. Jeffrey shared some staff experiences with the telephone script. It was stressed the eligibility workers should continue asking customers if it is a good time to talk as a common courtesy because the interview takes about ten minutes. 4. Renewal Postcards a. We reviewed details for the Kahuku Local Project to implement this activity and wrote it in the required Plan, Do, Study, Act (PDSA) format. Barbara will post the final version on the Process Improvement Collaborative web site and Hawaii Covering Kids web site (http://coveringkids.com/news/Section_193.asp). b. It was suggested that outstationed eligibility workers help customers report changes to Med-QUET. Currently, AlohaCare, Kaiser, and HMSA use form 1179 (Health Plan Change Report Form) which could be adapted. Barbara will discuss the idea with Kookie. 5. Notices Med-QUEST’s applications and renewal letters are now “customer friendly,” therefore it was suggested that notices Med-QUEST sends to customers be reviewed for similar style and content. This task will be delegated to the Process Simplification Task Force. 6. Procedures for Renewal Letters Returned to Med-QUEST by Post Office Procedures were written by the Renewal Simplification Workgroup on 04/08/04 and reviewed at their recent meeting on 06/03/04. Angie Tam Sing, Eligibility Branch Administrator, sent an email to the supervisors explaining the procedures. If there are problems, the workgroup will discuss them at the next meeting. 7. Verification Checklist Some eligibility workers continue to request unnecessary documentation from customers and we discussed designing a verification checklist as a desk aide to eliminate this problem. We reviewed samples from other states and Alan will draft a Hawai‘i version for us to review at our next meeting (we found August’s Plan, Do, Study, Act!). 8. Closure Codes a. Nicole Ravenell from Covering Kids & Families suggested we contact Ruth Kennedy in Louisiana to discuss eliminating unnecessary closure codes. Ruth explained that her staff reviewed the relevance for closing cases, eliminated TANF reasons, and found those of statistical interest. Louisiana has approximately twenty codes, however only three are for procedural reasons: Failed to Return the Form, Returned the Form Without Essential Verification, and Unable to Locate. The others are reasons the customer is not eligible for the program such as age, residency, income, etc. b. We reviewed Med-QUEST’s “List of Denial Closure Reason Table” to parse out procedural reasons. There are seven: Social Security Number, Non-Compliance with Child Support, Failed to Provide Required Information, Did Not Pay Premium Share, Failed to Submit Transitional Medical Income Verification, Failed to Appear for Interview, and Whereabouts Unknown. We decided our codes should not be constrained further because the data could limit identification of specific problems. c. Barbara suggested Alan share data we use for policy recommendations with eligibility branch staff to emphasize inputting accurate denial and closure reasons is imperative. 9. Improving Customer Service Barbara shared copies of two reports, “A Focus Group Study of Uninsured Children in Hawaii” and “A Focus Group Study of Pregnant Women About Health Insurance,” and subsequent feedback from community organizations about improving Med-QUEST’s customer service. We decided to talk with the Women, Infants, and Children Program (WIC) because they are a similar needs-based government agency. Barbara will invite Sue Uyehara, WIC’s Program Support Section Chief, to our next meeting to share successful strategies.