Thursday, 4 January 2007 Evaluation and Identification/Outreach Present: Melba Bantay (Catholic Charities Hawaii Immigrant Services), Waynette Cabral (State Planning Council on Developmental Disabilities), Cliff Cisco (HMSA), Jennifer Diesman (HMSA), Josh Green (State Representative), Dee Helber (Hawaii State Department of Education Student Support Services), Bill Kaneko (Hawaii Uninsured Project), Barbara Luksch (Hawaii Covering Kids), Ruth Ota (Hawai‘i State Department of Health Public Health Nursing), Marika Ripke (Hawaii Kids Count), Rochelle Sparko (Legal Aid Society of Hawaii), Kathy Sthay (American Academy of Pediatrics Hawaii Chapter), Donna Tsutsumi-Ota (MothersCare), and Sylvia Yuen (University of Hawaii at Manoa Center on the Family). 1. Welcome and Introductions Barbara thanked everyone for taking time from her or his busy schedule to join our meeting. We discussed how to help the remaining uninsured “gap group” kids with a goal of reducing the number of uninsured children in Hawai‘i from 5% to less than 2%. The remaining 2% will be children in families who choose not to participate in health insurance plans. 2. Review Minutes from 10/04/06 Evaluation Task Force Meeting a. Barbara said updated data show the annual number of uninsured newborns is 363. b. We thanked HMSA for its children’s health insurance plan because it is the only low-cost option available in Hawaii. Cliff noted there are currently 1,415 participants. c. QUEST Spend-Down could be an option if a child is not eligible for QUEST because the household’s gross income is above 300% FPL. Some deductions can be calculated, however there must be parental deprivation (e.g., a parent is unemployed, absent, disabled more than thirty days, or incapacitated). Medicaid Fee-for-Service has a similar income spend-down provision for blind and/or disabled children wherein parents pay a portion of the bill (e.g., cost-share). Children’s QUEST and Medicaid Fee-for-Service spend-down situations are extremely rare, especially with Hawaii’s 300% FPL level for public health insurance. d. Jennifer explained that after a baby is discharged from a hospital, HMSA’s private plans cover newborn well-child checkups under the mother’s health insurance for the first thirty days of the baby’s life. This does not include emergency or other health care services. According to the Prepaid Health Care Act (HRS §393-7), similar health plans must follow what the prevailing plan covers. Kaiser is not considered a similar plan, therefore Barbara will research their newborn coverage. e. Barbara noted when Hawaii expanded its QUEST and Medicaid Fee-for-Service programs to 200% FPL in July 2000, it also established a state-funded component for lawful permanent resident children who have been in the United States less than five years and children from the Freely Associated States. Costs are covered within the 10% Tobacco Settlement Fund allocation required to pay for children’s health insurance. It is administered by Med-QUEST as a Medicaid-clone program using its forms and processes. f. Melba clarified most lawful permanent residents get jobs immediately after arriving in Hawai‘i and many employed by the service industry receive dependent health insurance coverage. g. Donna explained pregnant teens are covered either by their parents’ health insurance or Med-QUEST’s programs. Extensive outreach is conducted by Hawaii Covering Kids targeting pregnant teens and the challenge is assuring their newborns are enrolled in QUEST or Medicaid Fee-for-Service within five days of birth to cover all hospital expenses. 3. Hawaii Covering Kids Priorities a. State pays monthly premiums for children enrolled in QUEST-Net (251-300% FPL). This is our absolute top priority. b. Uninsured newborns ineligible for QUEST or Medicaid Fee-for-Service and unable to enroll in HMSA Children’s Plan until 31 days old. They are born to uninsured mothers or are only covered by mother’s health insurance plan for well-child care after hospital discharge until they are 30 days old. c. Immigrants with temporary visas (e.g., V, H, K, J, F2) and undocumented immigrants in Hawaii less than six months. They do not meet six-month residency requirement for HMSA Children’s Plan. 4. Other States Expanding Programs to Cover All Children Barbara mentioned some other states: a. Illinois (“All Kids”): Added health insurance option so families who do not qualify for Medicaid or Children’s Health Insurance Program can purchase coverage for their children. b. Pennsylvania (“Cover All Kids”): Children’s Health Insurance Program sliding scale premiums if annual household income is between 200-300% FPL, exceptions for some who are above 300% FPL, and assist families with private health insurance premiums. c. Washington: Expansion of Children’s Health Program for non-citizen children, develop a program to help small employers offer affordable family coverage, and payments to families for employee’s premium contribution. We are interested in their successes as well as implementation problems. 5. Brainstorm Health Insurance Solutions for Uninsured “Gap Group” Kids a. Legislative bill for a three-year pilot program to cover monthly premiums for children enrolled in QUEST-Net (251-300% FPL). This is our top priority. b. Separate legislative bill for a three-year pilot Keiki Care health plan similar to HMSA Children’s Plan: * Available to uninsured children and youth; * Ineligible for QUEST or Medicaid Fee-for-Service; * Ages one day old to eighteen years old; * Hawaii residents (no length restriction); * Free limited benefit package; * Physician reimbursement on par with QUEST; and * State money allocation capped subsequently enrollment capped. Notes * State funds will go to the Hawaii State Department of Human Services, however Keiki Care will be managed by a mutual benefit society. * The task force members want a simple evaluation component to determine if Keiki Care is reaching our target groups (e.g., uninsured newborns, undocumented immigrants, and immigrants with temporary visas). Barbara and Marika volunteered to design an optional anonymous application page with outreach questions. Hawaii Covering Kids will collate the data. * Cliff explained HMSA will continue its Children’s Plan so it is available after the three-year Keiki Care pilot program ends. 6. Next Steps Barbara will contact task force members for further ideas regarding 5b and Josh will email Barbara the draft bills for 5a and 5b to share with the task force members. Friday, 19 January 2007-Wednesday, 28 February 2007 Outstationed Eligibility Workers Six meetings were held with community health center outstationed eligibility workers, hospital outstationed eligibility workers, and Med-QUEST staff. Present Hilo (01/23/07): Gail Inoue (Med-QUEST), Barbara Luksch (Hawaii Covering Kids), Camille Mehau (Bay Clinic), Nan Tome (Med-QUEST), Georgie Sampaga (Bay Clinic), and Susan Taira (Hilo Medical Center). Kauai (01/19/07): Blaine Akagi (Med-QUEST), Barbara Luksch (Hawaii Covering Kids), Laverne Tsukamoto (Kauai Veterans Memorial Hospital and Samuel Mahelona Memorial Hospital), June Munoz (Kauai Community Health Center), Iris Venzon (Med-QUEST), and Charlene Yamamoto (Kauai Community Health Center). Kona (01/26/07): Gladys Ablao (Hamakua Health Center), Florence Ashihara (Med-QUEST), Norma Crouch (Kona Community Hospital), Pili Kane (West Hawai‘i Community Health Center), Barbara Luksch (Hawaii Covering Kids), Ann Mortensen (West Hawaii Community Health Center), and Emily Takaya (North Hawaii Community Hospital). Lanai (02/28/07): Alton Aoki (Med-QUEST), Diane Jacobs-Belez (Lanai Women’s Center), Wilma Koep (Lanai Women’s Center), Barbara Luksch (Hawaii Covering Kids), and Juliann Mock Chew (Ke Ola Hou O Lanai). Maui (02/01/07): Natasha Andaya (Community Clinic of Maui), Noe Lecker (Häna Community Health Center), Barbara Luksch (Hawaii Covering Kids), Cristina Munoz-Barrantes (Community Clinic of Maui), and Gail Omura (Med-QUEST). Molokai (02/06/07): Cedric Alonzo (Molokai Community Health Center), Debora Eala (Molokai Community Health Center), Linda Lidstone (Med-QUEST), Barbara Luksch (Hawaii Covering Kids), Desiree Puhi (Molokai Women’s Health Center), and Phoebe Starkey (Molokai Women’s Health Center). 1. Welcome and Introductions Barbara thanked everyone for attending the meetings and explained the purpose was an informal discussion about current Med-QUEST eligibility topics. 2. Med-QUEST Eligibility Updates a. Barbara reminded participants about the children’s income guidelines effective 1 October 2006. Household income limits for the QUEST and Medicaid Fee-for-Service programs for children and youths ages 0 through 18 years old increased: up to 250% FPL —Free 251-265% FPL QUEST-Net—premium share is $15 per month per child 266-280% FPL QUEST-Net—premium share is $30 per month per child 281-300% FPL QUEST-Net—premium share is $60 per month per child The 2006 gross family income limits for free public insurance (250% FPL) is $57,504 per year for a family of four and it is $69,011 for a family of four for the premium-share public health insurance (300% FPL). The 2007 gross family income limits for free public insurance (250% FPL) is $59,400 per year for a family of four and $71,280 for a family of four for the premium-share public health insurance (300% FPL). b. Barbara distributed eligibility and benefit information on the HMSA Children’s Plan that costs $51 per month per child. It was suggested outstationed eligibility workers and Med-QUEST staff tell families who are denied public health insurance for their children due to income or immigration status about this plan because it is the only low-cost option available in Hawaii. c. A new adult coverage expansion called QUEST-ACE will begin 1 April 2007. It is for 19-64 year olds with household incomes between Medically Needy-100% FPL. It will be a QUEST-Net benefit package with limited prescription drug and hospital coverage. More details will be available closer to implementation. d. Mandatory QUEST plan re-enrollment is April-May 2007 and effective July 2007. 3. Medical Emergency (ME) Process and Form 1149 a. It should only be used only if treatment, medication, or medical supplies for life-threatening conditions are not available without health insurance. b. It should not be used: person is receiving treatment; nursing home placement; child needs health insurance to participate in school activities; physician wants to speed up payment from Med-QUEST for health care services; or other situations that don’t meet the criteria explained in 3a. c. Form 1149 should be submitted with an application. If an application is already registered at the Med-QUEST office, it should be sent separately with information at the top of the form indicating the application date. d. If the applicant does not have copies of U.S. citizenship/alien status documents and/or photo identifications available, Med-QUEST will expedite application processing for emergency benefits only and pend for these documents. e. It is helpful for hospitals to attach a copy of the emergency room discharge document if prescription drugs are needed. f. Suggestions for revising form 1149 included: * It does not guarantee eligibility. * Explanation of “emergent condition” and emphasize the form is only for life-threatening emergencies. * Treatment the patient needs is ____________________. * The treatments, medications, and/or medical supplies that are not available to the patient without health insurance: * The medical condition must be treated within 48 hours or ___ days. * Revise or delete long paragraph at the end because it is incomprehensible and few people read it. We agreed there must be a Med-QUEST procedure to screen out inappropriate 1149 submissions so they don’t interfere with other applicants waiting for determinations. 4. U.S. Citizenship/Alien Status, and Photo Identification Documentation Feedback from the groups included this information: a. Out-of-state birth certificates for applicants are not only costly but also difficult to obtain because of different state rules and forms. Furthermore, these birth certificates often take longer than time allotted for Med-QUEST application processing. Hospital representatives explained these situations require accepting sliding scale payments and using the Med-QUEST denial letter for charity eligibility. b. Some BESSD workers are entering codes to bypass HAWI’s U.S. citizenship screen. When it becomes a medical-only case, there is no U.S. citizenship document in the file and Med-QUEST must follow-up with the customer. This creates not only extra work for Med-QUEST staff, but also a problem for the customer who may not respond to Med-QUEST’s inquiries and thereby risks losing public health insurance coverage. c. All participants agreed that if a customer hasn’t responded to X072, X073, and numerous other letters requesting documents, Med-QUEST should send a notice with a closure date. Most customers will respond because they want to keep their health insurance while others may have moved or are receiving employer-sponsored health insurance. Med-QUEST eligibility workers and outstationed eligibility workers base this recommendation on their extensive experience. d. Some customers are attaching birth certificates to form 8000M and sending it to the local Med-QUEST office. Barbara explained designated document sites assisting people who receive blue letters (X072 and X073) have contracts from the Hawaii State Department of Human Services through the Hawaii Primary Care Association. The site is reimbursed for documents, digital or Polaroid camera, and portable photocopy machine. Reports and invoices should be sent to Barbara. 5. Other Da Kine a. 1108 is a vital process simplification component for children and pregnant women because it does not have an absent parent question. In the past, some parents, guardians, and pregnant women refused to apply for health insurance due to abuse fears, therefore publishing 1108 has helped Med-QUEST better serve the public. b. We reviewed revisions to form 1123 (HIPAA), including designating an organization rather than individual and listing and termination event rather than date c. Suggestions for updates to 1100 and 1108 are: * Income: School Grants, and Scholarships: write type and dates * Assets: change Trust Funds to Family or Individual Trust Funds * Allow space next to “(write who pays you)” * Reinsert question about losing employer-sponsored health insurance. d. Suggestions for “Question and Answer Guide” updates are: * Can college students who are home during school breaks apply? * Explain school grants and scholarships exempt from income calculations (e.g., Pell Grant, tuition assistance, etc.)? * Information about involuntary separation of household member. * People who work odd jobs for cash or get money from family members should write the gross monthly amount in 4B next to “Other Income.” e. Barbara reminded meeting participants that Malama i na Keiki 8 is 16 March 2007 and the registration deadline is 23 February 2007. f. Some hospital patients who are lawful permanent residents claim they are undocumented immigrants because they are uninsured and afraid their sponsors will get in trouble. 6. Follow-Up Information a. The current turnaround time for people to get copies of birth certificates on all islands is four to six weeks, except Honolulu walk-ins who can get same-day service. There are no plans to process birth certificates on Neighbor Islands due to lack of District Health Office staff and security issues. b. Research did not locate a scanner or photocopier that runs on batteries and could be plugged into a motor vehicle charger. A different solution might be a cellular telephone that takes clear pictures of people and documents. c. It was suggested Hawaii State Department of Health birth and death certificate request forms be posted on the Hawaii Covering Kids web site in the library of forms. This was completed.