In January 2010, at the White House Forum on Modernizing Government, President Obama noted that, “Improving the technology our government uses isn’t about having the fanciest bells and whistles on our websites – it’s about how we use the American people’s hard-earned tax dollars to make government work better for them.” Now, six months later, the newly formed Enrollment Workgroup of the Health IT Policy and Standards Committees has begun the discussion of how to bring eligibility determination and enrollment in health and human services programs into the 21st century.
What we critically need—and what these standards have the promise to support—is an eligibility and enrollment system that will make applying for health insurance and other human service programs as easy as using the Internet to pay your bills or file your income taxes. It should be possible to apply for programs online, easily obtain the documents and information needed to confirm eligibility, and re-use this information to apply for a variety of programs, and re-certify your eligibility when the time comes. We need your help to uncover the examples, insights and best practices that will make this effort successful.
As background, the Enrollment Workgroup, authorized by the Affordable Care Act (ACA), has been tasked to recommend a set of standards to facilitate enrollment in Federal and state health and human services programs, including standards for:
- Electronic matching across state and Federal data
- Retrieval and submission of electronic documentation for verification
- Re-use of eligibility information
- Capability for individuals to maintain eligibility information online
- Notification of eligibility
To follow up on the June 14th Enrollment Workgroup’s first meeting and public hearing and to elicit further public comment, the FACA Blog is open for comments until July 1st. Comments can be submitted online on the blog website or emailed to: judy.sparrow@hhs.gov (use “enrollment workgroup” in header)
Specifically, the Workgroup would like public comment on:
(1) Federal, state, local or tribal government initiatives to simplify and streamline eligibility and enrollment in health and human services programs.
We would appreciate your insights on:
- How should this work support health reform goals, including simplified and streamlined eligibility?
- What standards are currently being used by state health and human services programs to determine eligibility?
- In what areas would additional standards create clear progress towards the goal of a seamless eligibility system for consumers?
- What standards or technology principles would enable rapid innovation in this space?
You might also describe your efforts, including use of standards and technology to simplify eligibility and enrollment, for:
- Front end check of eligibility/enrollment across multiple programs:
- How do you check eligibility/enrollment across programs at the front end? Which programs are included? Standards used?
- Approach and standards for data linking/matching? Is the matching probabilistic? What level of accuracy is required? Collecting information to determine multiple program eligibility
- What interfaces do you use to obtain electronic verification information? What standards used?
- Consumer entry of eligibility information, what data elements? Consumer authentication?
- What standards are used for messaging?
(2) Alternatively, if you are not in the healthcare sector, how have you solved challenges similar to those found in simplifying and streamlining eligibility and enrollment? In other words, how can we move towards 21st century practices?
- For example, share your perspectives on:
- Opportunity to move towards a web-services model
- Viability of a platform-based or enterprise service approach
- Role of consumer in managing own data
- Where we need standards to accelerate progress and consumer participation
Your responses will help form the agenda for the on-going work of the Enrollment Workgroup, and assist us as we work toward a September 30th deliverable deadline as mandated by ACA.
Thank you for your contribution!
– Aneesh Chopra, Chair, Enrollment Workgroup
– Sam Karp, Co-Chair, Enrollment Workgroup
Tags: Enrollment Workgroup, HIT Policy Committee, HIT Standards Committee
I have a little different point of view of the cyber health system challenges that first need to be addressed. In my opinion you are trying to build a cyber health system without a foundation. To that point, I would like to offer a cyber foundation that is comprised of separate database identifications for each and every imaginable health care related type of information. Just that simple, identify and address every possible type of health information. Then provide each database cell with regional definitions and cyber health system related resources (information and education related resources that are appropriate for a patient’s health and other circumstances).
Once a standard world-wide set of database identifications and addresses have been established, it should be quite simple to provide application software for any conceivable health-related purpose.
Simply put, identify, address, and define a standard all inclusive cyber health system database; provide a full spectrum of cyber health system application software; and provide United States citizens (health care providers or not) with access to the informational and educational resources of the cyber health system.
It should also be noted that we will only receive the most value from a cyber health care system that we can rely on with our lives. This could only be achieved on a cyber system that was completely secure, completely reliable, and could provide any level of privacy that was required by each and every cyber system user. With modest modifications, our current cyber systems could easily provide a safe, secure, and private cyber environment that would, in turn, provide cyber health resources that an Individual could rely on with their life.
Jeff Aronson
downtownwetmore@earthlink.net
(210) 490-3214
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To be successful, streamlining and simplifying eligibility across health and human service programs must go beyond the technical aspects of data collection and transmission. It will require policy and programmatic alignment as well. We recommend that at least the following three issues be addressed: (1) the size and scope of the eligibility data mandated must be manageable, (2) federal agencies must align program integrity rules with operations, and (3) the eligibility and enrollment systems used must be widely accessible to maximize points of entry.
First, data sets should be limited in scope to support ease of use. Data standards should be determined for a minimum set of essential data that are common across health and human services programs (e.g., family composition, income, other health insurance coverage, citizenship). Trying to standardize all data elements required for the operation and management of these disparate public programs will be difficult and may discourage enrollment by making the application process too lengthy and complex. A more realistic goal is to have the initial data set support the bulk of the eligibility process for the majority of the enrollees.
Second, federal agencies must align program integrity and operations. Health and human service program oversight spans multiple federal agencies, with each requiring a potentially different screening and eligibility determination process. For example, the method of determining family unit composition and calculating income, the acceptability of data sources and time period of information (e.g., last year’s tax return versus pay stubs from the past three months), and redetermination frequency may differ between Medicaid, welfare, food stamps, and other health and human service programs. With the program integrity requirements for each program set at its own standard, many eligibility and case workers feel the need to follow-up and verify components of an applicant’s information to ensure compliance with their own regulatory requirements instead of relying solely on the submitted application data through a single point of entry. The federal government will need to work across agencies to establish common definitions and specify acceptable documentation for each of the core eligibility elements before it can develop a unified system.
Third, the maximum number of points of entry into the system must be maintained. Many successful eligibility and outreach strategies rely on community-based organizations and facilitated enrollment assisters. These organizations generally do not have direct access to central enrollment processing systems and may face technological barriers. Data specifications for central eligibility and enrollment systems should be platform-independent and capable of interfacing with a variety of end-user systems to maximize points of entry and community outreach.
Modernizing eligibility systems to handle the increased needs related to health care reform will require more than data collection and transmission. It must also align separate policies and procedures of the different users into a unified system that allows for ease of use, minimizes use of independent systems for verification, and supports multiple points of entry. In essence, reform of the eligibility system must be viewed as a reform of the “system” in its broadest definition.
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I am excited by this national effort to enable streamlined eligibility for health and human service programs. As a social worker I know from experience that people applying for Medicaid are very likely to need other services to become healthy and self-sustaining. I also know that the proactive effort of identifying these other needs and the needs of family members goes a long way in preventing individuals and families from going into crisis and becoming homeless, unemployed or progressing to a more debilitating or chronic health condition. The work that was done to implement the Personal Responsibility and Work Opportunity Act and the Workforce Investment Act can shed light onto technologies and practices that worked well for exchanging information for the purpose of streamlining eligibility determination and enrollment. While this workgroup has a focus on implementing the health care reform legislation, I hope that we keep this greater eco-system and holistic client perspective in mind.
IBM joined the quest for integrated service delivery in health and human services more than a decade ago. In that time we have worked with federal, local, and multi-jurisdictional organizations to offer a more client-centric, out-come focused service delivery model. Through our experience we developed a framework that breaks down the business components of the service delivery eco-system so that organizations could better understand all of the ways in which an individual might touch the network of benefits and services offered. This structure then enabled creation of cross-program initiatives aimed at simplifying service delivery from a client perspective and at obtaining better outcomes and efficiencies from a program perspective. At the same time we were early leaders in the patient-centered medical home movement, culminating in co-founding the Patient-Centered Primary Care Collaborative, and in health information exchange solutions, including our ongoing role in the Nationwide Health Information Exchange.
We have worked with several organizations looking to implement cross-program eligibility systems. Through that effort we understand that while enrollment may seem easy to integrate, a lot of effort is expended in defining terms so that data can be pulled and re-used or entered only once. An early focus on program eligibility data definitions will help to identify which programs are most easily integrated and which will require more work to get accurate and simple business rules and client questions. An iterative eligibility process is also a good practice for streamlining the client’s effort. This might involve an eligibility assessment tool (anonymous or not) that culls out the programs for which an individual or family is most likely eligible. A more robust eligibility determination system then contains all of the required business rules to establish eligibility for each program. A final example is our work supporting HIE development and the lessons learned regarding the value of governance and data use agreements. Creating the open, scalable, standards-based solution was almost the easy part in comparison to the work the participants needed to do in order to have the trust and confidence that the right data was going only to where it needed to go. For additional information on our observations and recommendations for improved health and human services, please see our white paper “What’s Next? Becoming a More Effective, Efficient, and Responsive Social Services Organization” at ftp://public.dhe.ibm.com/common/ssi/sa/wh/n/gvw00179usen/GVW00179USEN.PDF.
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Dear Co-Chairs Chopra and Karp and Members of the Workgroup:
The County Welfare Directors Association of California (CWDA) writes to offer some thoughts for the Enrollment workgroup as you work to meet the challenging tasks before you. CWDA is a nonprofit association representing the human service directors from each of California’s 58 counties. In California, county human services departments determine eligibility for Medicaid, TANF, and SNAP benefits. As an order of magnitude, our departments manage the enrollment for 4.5 million Medicaid clients, 3 million SNAP recipients and 1.1 million TANF recipients at any given point in time, plus the processing of tens of thousands of new applications each month across the three programs.
In order to maintain high standards of program accuracy, efficiency, and customer service, county human services departments have taken a lead role in developing modernized enrollment systems that support our network of eligibility workers in their daily tasks and make enrollment and benefit retention easier for our clients. Specific examples of these advances include:
1. Development of Internet-based applications for Medicaid, TANF and SNAP benefits — Our automated systems have developed integrated Internet applications and work continues to further enhance the capabilities of these systems, which will provide the state with a foundation for implementing the federal standards your workgroup is developing.
a. The C4Yourself system is accessible to all residents in the 39 counties that use the C-IV computer system as of June 28. The system is continuously being enhanced, with further functionality added in. The next phase will allow all clients to access their case file information. Customers will have the ability to submit required periodic reports via the Internet and will also be able to communicate with their eligibility workers via a secure Internet messaging system.
b. Phase I of LEADER Web, which is used in Los Angeles County, enables clients to view benefit issuance information, the status of their application and periodic reports, and
c. The Benefits CalWIN system is operational in several pilot counties and will be expanded to all 18 counties that use CalWIN by November 2010. The Internet application will be fully integrated into the CalWIN system and also allow for Internet submission of periodic reports and annual renewals.
2. Use of Customer Service Kiosks in Community locations — Merced County is piloting self-serve, ADA compliant kiosks. This month, kiosks will be installed in a variety of community locations such as health clinics, pharmacies, libraries, WIC offices, resource & referral organizations, and employment & training centers. Applicants and clients will be able to use the kiosk to access the web-based system to apply for assistance, update eligibility information, print information and forms, and use a telephone to access county social services staff for assistance. Future enhancements include web-cam connection to social services assistance staff and the ability to scan documents for submittal.
3. Use of Document Imaging — California counties are expanding the use of document imaging, with full case imaging in all programs planned by the end of 2012. Using this technology we will be able to retain client documents, making it unnecessary for families to resupply key materials when applying for new programs and facilitate staff’s ability to quickly respond to client inquiries through immediate access to all critical client information. In addition, we are piloting several approaches to client self-service, where clients can scan and submit their documents electronically, avoiding the need to mail or deliver documents.
4. Development of Interactive Voice Response Capacity — Interactive Voice Response (IVR) technology (now available in many counties with statewide implementation complete within the next year) provides key information via the telephone. Using this technology, clients can check their benefit levels, verify their address, ensure that their latest status report has been received, and confirm when their next eligibility determination is due – to name just a few of the possibilities. This technology also makes it possible to notify clients of due dates, send appointment reminders, and broadcast telephone messages to all clients. The IVR will increases eligibility retention by easing access to information and reminding clients of critical appointments.
California’s counties are committed to providing modernized, efficient, effective customer service. Ensuring a comprehensive, client-friendly and simple approach to health care reform, especially for low-income Medicaid clients, is vital to developing the “culture of coverage” envisioned by the federal government. California’s counties are prepared to take full advantage of the opportunity the new law presents to ease enrollment and retention for millions of Californians.
We know that you face a tremendous challenge in developing recommendations that can work for the entire country. We stand ready to lend our expertise to this effort. We support the adoption of a “no wrong door” approach that allows enrollment via multiple paths and provides two-way coordination between state health exchanges, the agencies that administer Medicaid and other public programs (i.e., the counties in California) and state CHIP programs, depending on the path each individual uses. As you know, the PPACA contemplates an Internet-based enrollment option in addition to enrollment in-person, by phone and by mail and requires seamless transitions between public programs for individuals. We stand ready to help develop such a system.
Contacts for further information about CWDA and California county efforts are:
Meg Sheldon
Information Technology Associate
County Welfare Directors Association of California (CWDA)
925 L Street, Suite 350
Sacramento, California 95814
916-443-1749
msheldon@cwda.org
Cathy Senderling-McDonald
Deputy Executive Director
County Welfare Directors Association of California
925 L Street, Suite 350
Sacramento, CA 95814
(916) 443-1749
csend@cwda.org
Tom Joseph, CWDA Federal Representative
Waterman & Associates
900 Second Street NE
Washington, DC 20002
(202) 898-1444
tj@wafed.com
Sincerely,
Frank J. Mecca, Executive Director
County Welfare Directors Association of California
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Single Stop USA applauds the efforts of the Enrollment Workgroup and would like to share some background about how our organization approaches these issues.
Single Stop USA is a national nonprofit organization whose vision is to cut across silos and facilitate the development of client-centered, integrated systems that help students and families to achieve economic security through coordinated access to critical supports and services. We do this through our program model, strategic initiatives and policy work.
Program Model
The Single Stop program model consists of four parts:
1. Benefits screening and counseling that relies on a full-time caseworker and the Benefits Enrollment Network (BEN).
a. BEN is a comprehensive web-based technology platform that simplifies, accelerates and streamlines the savings-assistance and benefits enrollment processes. Fully integrated with Microsoft Dynamics CRM, an enterprise-class, case management system, BEN facilitates integration and coordination across multiple sites and stakeholders, bridges critical gaps in service delivery, and enhances the capacity of its national network of users to serve clients more efficiently, more accurately and more effectively.
2. Free tax preparation,
3. Legal Counseling, and
4. Financial Counseling
Last year, Single Stop’s model helped 120,000 families access $300 million worth of benefits, tax refunds and services, including Medicaid, CHIP, SNAP, EITC, LIHEAP and more. That’s an average of $2,500 in supports per family. $2,500 that augmented income, allowed for preventive care visits, paid for nutritious food, rent or electric bills, or was set aside as savings.
Strategic Distribution Channels
Second, Single Stop identifies non-traditional distribution channels for its service delivery model that reach more people, have greater impact and can lead to institutionalization and sustainability. Community colleges are one such channel. With community college sites in four states, and system-wide partnerships with three of the country’s largest systems, we expect to provide services to thousands of students next year, helping them to access benefits and supports worth over $40 million, supports that will help them to stay in school and reap the increased earnings rewards of a higher education.
Public Policy
Third, our policy work builds on what we learn from our program model and strategic initiatives. Single Stop believes that the silos and barriers to access should also be addressed through changes in public policy. We applaud the Enrollment Workgroups efforts to develop standards and technologies that make the enrollment processes less burdensome for struggling families. The improved coordination of public supports will help families better combat the intertwined forces that lead to economic insecurity, poor health, and general instability.
We support efforts to provide “no wrong door” for all work support programs, simplify the process of applying for multiple benefits and encourage participation, a role for nonprofits in benefits delivery, the use of technology combined with expert counselors to deliver multiple benefits, and continued investments in benefits access innovations at the Federal, State and Local levels.
Thank you.
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In Santa Clara County, California we have participated in a number of initiatives to streamline enrollment in health coverage programs, including utilization of the web-based applications Health-e-App and One-e-App. Additionally we have several home grown systems to streamline various aspects of enrollment. Lessons learned from these systems are as follows:
- Coverage programs have varying enrollment requirements, income calculations, coverage periods and are administered by distinct agencies using distinct information systems. Standards governing what information is collected, what income counts, how family size is derived, etc. is essential for coordination and communication among these programs. Better yet, streamlined systems for eligibility determination and/or administrators may facilitate the best outcomes.
- We have developed manual and automated processes for verifying existing coverage/applications at the front end prior to initiating a new application for health coverage programs. We found this to be an essential step as some consumers are not aware of their coverage or existing pending applications. For Medicaid we may call our local Social Services Agency to check to see if a consumer already has coverage or has a pending application. This is a critical step to reducing redundancy and improving the user experience.
-Back-end processing of documents submitted in conjunction with an online application has been problematic. Significant inefficiencies seem to exist at this stage resulting in erroneous denials, approvals, and consumer frustration. We hear from consumers that the support systems (consumer assistance lines) established to deal with these types of issues are insufficient and that issues are not resolved efficiently.
- Coordination with local governments. Many Counties and public health care systems have staff dedicated to helping patients/consumers access appropriate health coverage but they have limited access to information to make this effort most efficient and beneficial for the consumer. Could the information from the web application be downloaded, interfaced, or sent to local county software applications (which would ideally be also web-based), and perhaps a subsidiary of the larger State Wide Web application?
- In California, as in many States, immigrants constitute a significant percentage of the population. Some groups have reservations about applying for publicly funded programs. How information is protected and with whom this data will be shared should be clear and controlled by the applicant.
- Obtaining verification documents is a significant barrier to enrollment. Locally we purchased birth records for California and developed a simple but effective database in which staff can very US birth immediately and electronically. This type of electronic and real time verification should be available for all US citizens.
- A large percentage of consumers are motivated to apply for health coverage at the point in which coverage is needed. Systems must be able to respond to this immediate demand both for consumers and for providers. This is a significant concern for public hospitals and community based clinics that serve a large number of uninsured patients. For these systems screening is often concurrent with the point of service.
Ideally clients should be able to access a web based application for the following services:
• Check their eligibility for county, and all other programs, including Medicaid, Medicare etc.
• Complete an “online financial household profile” (which would serve as an on-line equivalent to a financial counseling interview)
• Begin and complete the requirements necessary for a Medi-Cal application
• Make appointments with local “Financial Counselors” or Eligibility Workers as appropriate
• Serve to be a one stop on-line “shop” beyond CalWin applications that would allow the individual counties to download or in some way transfer the data and information provided to applications for County Specific Coverage Initiatives etc.
• Be “Generic” Enough to have information that would provide “complete” informational requirements for the specific county but not ask specific questions that are “county specific” so that the process to complete is too cumbersome for the individual to complete.
• Provide facility for clients to “save” what they have provided and have a “Summary or Work List” of what is still required in order for them to complete the process.
• Permit “on line” assistance from a local financial counselor (via chat or phone) who may be working at a local financial counselor call center
• Clearly and simply provide work sheets on line to assist clients
• Identify what documents are necessary for application
• To interface to other local or county specific software programs which would could possibly be “individual sub programs on this same web based portal” which specifically produce the locally specific applications.
• To consider generic applications for local usage
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Thank you for the opportunity to provide input to the Enrollment Workgroup on standards to facilitate enrollment in Federal and state health and human services programs. I write on behalf of CLASP, a nonprofit organization that develops and advocates for federal, state and local policies to strengthen families and create pathways to education and work in order to improve the lives of low-income people.
We urge HHS to take all steps possible to ensure that the systems being developed to promote access to health insurance can also be used to provide access to the full range of public income- and work-support programs. In addition to making application processes more efficient and less duplicative, ensuring access through the systems you are developing is important because these programs also contribute to public health. They enable families to purchase nutritious food and to live in homes free of lead or other environmental toxins, and reduce poverty-induced stress.
When health care reform is fully implemented, millions of Americans will interact with these new systems to learn about different health care plans, and to apply for subsidies or coverage. This represents an unprecedented opportunity to inform visitors of their potential eligibility for other benefits or credits, such as SNAP, WIC, TANF, child care subsidies, or the Earned Income Tax Credit, and to simplify the process of applying and documenting eligibility for these income- and work-supports. By contrast, if these programs are not incorporated into the systems, participation may actually decline, as many families currently learn of their eligibility for other benefits when they apply for Medicaid or SCHIP benefits.
In most states, the enrollment process for public benefits is uncoordinated and duplicative, burdening families with trips to multiple offices, and repeated requests for the same documentation. The principles behind improving health care access – providing “no wrong door” for applications, relying on information technology to provide documentation of eligibility from existing sources rather than asking customers to provide it, storing documents for future retrieval – can also transform the enrollment process for other programs.
We recognize that the health care reform legislation sets an ambitious timeline, and that the statutory mandates for providing information about and access to the different types of health care assistance will be challenging to implement without the complications of additional programs. However, it is far simpler to add new functions to a system when the possibility of such staged additions is envisioned and planned for up front, rather than added as an afterthought once the system is up and running. Moreover, we simply cannot afford to continue to pay for the development of duplicative, siloed computer systems.
HHS can take action now to ensure that the health insurance portals can be the backbones for a system that allows access to the full range of income and work-supports. We urge HHS to:
• Develop model data and administrative systems and encourage states to use them.
• Provide higher rates of reimbursement to states for developing information systems based on open-source tools that can be shared among states and that allow technology providers other than the original developers to add functionalities in the future.
• Clarify and simplify “Advanced Document Planning” and cost allocation requirements to encourage states to build multi-program systems rather than separate systems for each program.
• Require portals to accept and export data in standard machine-readable formats so that information can be automatically transferred between health care portals and other state systems. This will also allow for third-parties to provide application assistance.
• Clarify and standardize federal requirements regarding electronic applications and e-signatures.
• Encourage states to use Medicaid and CHIP outreach efforts to enroll customers in the range of public benefit programs.
• Provide clear guidance and technical assistance regarding the applicability of Americans with Disabilities Act rules to online systems, and the need to provide alternative application mechanisms for individuals unable to use them.
Thank you for your consideration. We appreciate your efforts on this most important project.
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Currently, the our state’s public assistance agency has an integrated approach to assistance programs eligibility screening for Medicaid, Temporary Assistance for Needy Families and SNAP. When our agency currently determines eligibility, files from the Social Security Administration, the Eligibility history database, National New Hire Database and veterans/military databases are used. At this time, we do not have linkages with our State Department of Revenue that handles tax returns. When linking data/matching, our agency uses a standard probabilistic matching algorithm that includes name, sex, address, birthday and social security number. A social security match is the most accurate. A web application provides real time screening of the eligibility information a consumer enters and a second web application collects more detailed demographic and financial data to feed the application process. Those who prefer to provide a paper application, a similar process is provided to the staff member who processes the application on behalf of the client. XML based standards and a Secured Socket Layer (SSL) are used for security when messaging. The Client Eligibility System, which is used to determine program eligibility, provides industry standard security to the data and the transactions processing the data.
Going forward, health reform goals including simplified and streamlined eligibility can be supported through guidance, coordination and additional funding from the federal government to states. Specific areas where additional guidance and/or assistance would significantly assist planning and implementation for eligibility systems are as follows:
• Guidance regarding the ACA legislation’s new standard for eligibility determination, Modified Adjusted Gross Income (MAGI): MAGI appears to be based on tax filings. Specific information is needed on how states will handle income changes that occur during the year after taxes are filed. Also, as some states are in the process of obtaining a new system, requirements are needed as soon as possible.
• There are also new requirements to simplify eligibility determination. States will need assistance in funding these new requirements as well the implementation of the MAGI system.
• FNS and CMS coordination, as many states operate an integrated eligibility system: States will benefit from having one set of requirements and approval of funding instead of having to obtain separate approvals and requirements from two agencies.
• Enrollment guidance: It is our current understanding that for the purposes of Medicaid reimbursement, states will be required to determine Medicaid eligibility both under a new eligibility standard in 2014 and under the current eligibility standards. Combined with increased enrollment, there is significant concern as to system capacity and ease for clients as they interact with this system. Additionally, if states decide to operate an Exchange and use their current eligibility system to conduct eligibility for the tax credits, the open enrollment requirement could be problematic, as currently the Medicaid system is based on rolling enrollment.
• For states that choose not to operate an Exchange, more specificity will be needed to understand how the federal Exchange will conduct Medicaid eligibility for individual states, and how eligibility information will be transmitted to states. For example, will the federal Exchange conduct full Medicaid eligibility and determine if a person is newly eligible for Medicaid, or eligible under the existing rules, or will they screen for eligibility and refer clients back to the State for a determination? Assistance accessing files with federal tax information and immigration status of applicants would also ease eligibility determinations.
Guidance and/or assistance in these areas will assist states as we plan and implement systems that include simplified and streamline eligibility.
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I would like to endorse the efforts of the Enrollment Work Group. The efforts of this group will further transparency and innovation in Government (Government 2.0) and will begin to create a foundation to better coordinate consumer care, access and outcomes.
How this supports health reform goals, including simplified and streamlined eligibility:
Tenets of health reform include enhanced efficiencies, access, and improved outcomes. A focus on enrollment supports these goals. Consider efficiency. In February 2007, senior officials from Governor Bob Riley’s administration presented at the U.S. Capitol to the Alabama delegation and senior officials from the U.S. Departments of Health and Human Services and Agriculture. The focus was upon the duplicative, time consuming enrollment process that consumers had to engage in across multiple government health and human service programs, and how that impeded access to care. In January 2008, “Governor Riley launched the Connected Health and Human Services Framework (CHHSF)” as the cornerstone of an effort to implement a state-wide Health and Human Services (HHS) strategy that is highly integrated and family centered. http://camellia.alabama.gov/. Camellia is a computer tool to help gather information about Alabama’s resources and a person’s eligibility.
The methodology and approach that Alabama embraced was based on work they did with the Microsoft Institute for Advanced Technology in Governments and the Microsoft CHHS Framework: http://download.microsoft.com/download/2/5/0/250e30bf-0d81-4141-bf8f-4e4ad222fbfd/Microsoft_Connected_HHS_White_Paper.pdf
Alabama has been recognized the National Association of State CIO and other organizations for their Connected HHS initiatives: http://www.nascio.org/awards/nominations/2007/2007AL2-Camellia%20NASCIO%20award.pdf
Efforts similar to Alabama’s have been highlighted in recent years at the annual Stewards of Change forums at Yale University, which have focused upon interoperability across federal state and local health and human service programs to measurably improve consumer access and outcomes. (see, http://www.stewardsofchange.com/Pages/Index.aspx).
Two papers that have been presented at these forums, which describe policy benefits to leveraging IT to connect enrollment, intake and other potentially shared services include “From Urgency to Innovation” (http://www.stewardsofchange.com/Events/Pages/5thAnnual.aspx) and “Achieving the Consumer Centered, Connected Health and Human Services Vision.” (http://www.stewardsofchange.com/Events/pages/4thannual.aspx).
Increasingly, with respect to Health information technology adoption considerations of efficiencies are coupled with attention to sustainability. In April 2010, Governor Patrick hosted a by invitation only policy roundtable at the Microsoft New England Research Center in Cambridge Massachusetts. Participants included Governors Patrick, Douglas and Beebe, as well as David Blumenthal (ONC), and state HIT Coordinators, Medicaid Directors, and business leaders. A substantial focus was on HIT, economic development, and “sustainability”.
Importantly, when we consider sustainability of health reform HIT strategies ranging from EHR adoption, to HIE implementation, to Insurance Exchange development, the significant savings that could be accrued by leveraging shared services such as enrollment/intake across multiple federal and state programs could be repurposed to support sustainability efforts.
A shared services technology vision such as the Medicaid IT Architecture (MITA), and the Microsoft Connected Health and Human Services Vision (http://download.microsoft.com/download/2/5/0/250e30bf-0d81-4141-bf8f-4e4ad222fbfd/Microsoft_Connected_HHS_White_Paper.pdf) speak to the flexibility and extensibility of a shared services framework based on a Service Oriented Architecture and the importance of a business and technology roadmap. (see also the work of Rick Howard, CIO, Oregon DHS “The Case for a National Human Services Business Architecture” http://www.aphsa-ism.org/home/doc/09Conf/Session1-2RickHowardOR.ppt presented at the 42nd APHSA-ISM Conference 2009.
For purposes of enrollment/intake suffice it to say that coordinating intake across multiple programs will not only drive efficiencies and improve access, it will also leverage other shared technology tools which will further the same goals. For example in health IT a Master Patient Index identifies common consumers across multiple health services. Similarly, a Common Client Index (CCI), used in many jurisdictions, identifies common consumers of human services and other programs. Leveraging these tools with enrollment tools + case management and CRM tools presents greater potential to provide coordinated care to at risk consumers. Similarly, a “connected services hub” often used by Medicaid, and human services agencies enables services (such as enrollment, or CCI) to be shared across otherwise disparate systems. Data aggregation tools, and personal health records, can connect across multiple programs through a shared services architecture to improve analysis, planning, and consumer involvement. The key here is that these tools promote coordinated care. They do not have to be built and maintained as stand alone services. They can be hosted in the cloud, or on-premise or a hybrid. They can be shared and span jurisdictional and program boundaries. It is becoming increasingly irrelevant where data and applications are physically located (with appropriate controls, of course) but the cloud and web services open up new frontiers in efficiency and nimbleness and interesting new services applications and mash-ups.
These technology tools will help drive business innovation to achieve health reform goals. For example, the Medicaid populations among states often exceed 25% of the state population. Those percentages are significantly higher in the larger population areas. Similarly a common client index reveals that common consumers across multiple human services programs are disproportionally located in large urban areas. In those types of settings we will see the extension of medical home models to coordinate with community human service and education providers. These will leverage provider enrollment tools, case coordination tools, and tie to HIE’s. Examples of emerging models include the efforts of Health Choice Network in Miami-Dade, Florida. (http://www.hcnetwork.org/hcnetwork.htm).
Standards and technology principles which enable rapid innovation; standards used for messaging, movement toward a web services model:
There are business domain standards (HL7, HIPAA 5010, NIEM…), technology standards (TCP/IP, XML, WSDL, WS-*, …) and technical principles (service orientation, componentized design, ) that will come into play in the context of this workgroup. There are emerging innovations in the industry around enterprise search, data aggregation paradigms as well as the management and consumption of structured and un-structured data. Mature tools and standards used for messaging include XML, SOAP, REST, WS-Interoperability are prevalent today and broadly supported in the IT industry.
The opportunity to move towards a web-services model is supported by the maturation of cloud services, configurable rules engines, shared core rules plus multi-tenant capabilities that support locale specific rules as needed. Existence of proven web services standards and tools enable flexible, composite, mash-up applications. Cloud computing is evolving rapidly to support complex, mission critical business functions including the evolving security and privacy requirements associated with health and human services, all in a cost effective and environmentally sustainable way.
Methods of checking eligibility/enrollment across programs; consumer centered approaches:
Successful examples of checking eligibility/intake involve multiple programs, use of consumer entry of eligibility information, and specified data elements can be extrapolated to a national approach. The Camellia program, referenced earlier is an example.
SingleStop USA, (http://www.singlestopusa.org/) which uses a CRM like application that manages client and family demographic data and evaluates eligibility for major federal benefits programs, and handles enrollment and data collection for same. Programs covered include Food Stamps, public health insurance for children (CHIP), Medicaid, State and local health care programs, energy assistance, the Earned Income Tax Credit (EITC), Child and Dependent Care Credit, Child Tax Credit, and more. SingleStop helps facilitate the benefit coordination coupled with case management and related services approach with providers in New York, California, New Jersey, and New Mexico (soon to include Florida and other jurisdictions). Numerous branches of United Way of America have leveraged the same technology tools.
Engaging the consumer in managing their data supports goals of improved health outcomes, access and efficiency. San Francisco’s Benefits SF (https://www.benefitssf.org/) uses consumer friendly, accessible, web-based multi-program eligibility tools that are available 24/7, when and where it is most convenient for the client. A video describing benefits of San Francisco’s “no wrong door” approach can be found at: http://www.nwnit.com/success/articles/Video%20%20%20BenefitsSF–San%20Francisco%20No%20Wrong%20Door%20%20Benefits%20Portal.asp.
The New York State, Department of Health Medicaid program will leverage both HIE and personal health records to improve patient care. (see, Figge, James J., M.D., M.B.A., “NY Medicaid‟s HIE/Enterprise Architecture: Using Recover Act (ARRA) Funding to Improve Care for Medicaid Beneficiaries” presentation, MMIS Conference, Chicago, Illinois, 2009. http://www.mmisconference.org/MMIS2009_Presentations_PDFs/Tuesday/Value%20in%20Sharing%20Medicaid%20Data/Tuesday_ValueSharing_Figge_v2.pdf.
Increased consumer involvement will drive technology and business innovation. For example some jurisdictions are looking to create a “child passport” for children leaving custody of child welfare (and other agencies) which would provide them with accessible identify (and other) information. Access to their social security number, and other essential information will assist them in securing employment, housing and drivers licenses. Integrating relevant intake/enrollment data into a personal health record could facilitate this. Some jurisdictions are now planning between Medicaid and Child Welfare how to facilitate this type of approach.
In conclusion, the demand for efficiency, improved access, performance management, outcome measurement, and safety are driving the development of shared services. We can no longer afford to build redundant expensive, complex system. Moreover, mature tools, technology and standards are available. The Enrollment Work Group’s charge is both important and timely. Enrollment is applicable to health and human services – from insurance exchange, to Medicaid eligibility, to child and family programs. We look forward to continued collaboration with the Workgroup, and anticipate its results.
William O’Leary
Executive Director, HHS
US Public Sector, Health and Life Sciences
Microsoft Corporation
http://www.microsoft.com/hhs
Agree or Disagree:
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The state of Oregon very much appreciates the opportunity to submit these comments.
There are a variety of issues that have to be addressed, in one way or another, if we are to develop, in your words, “an eligibility and enrollment system that will make applying for health insurance and other human services programs as easy as using the Internet to pay your bills or file your income taxes … to apply for programs online, easily obtain the documents and information needed to confirm eligibility, and re-use the information to apply for a variety of programs.” In these comments, we raise many of these issues for
the Workgroup to consider. We recognize that some of the questions we raise address policy and/or legal issues that may be beyond the specific scope of the Workgroup’s charter, but we believe that the Workgroup will benefit from being aware of all of these questions and concerns.
As the Workgroup discusses the question of how to efficiently and effectively transmit information between databases, we want the Workgroup to be keenly aware of what information Medicaid requires, and to be aware that, for example:
1. Some of the information Medicaid requires is not currently in any up-to-date, reliable database. In some cases, the Federal government could take steps to remedy that fact. In other cases, the relevant information is, inherently, information that will have to be retrieved ‘by hand,’ as it were, from individual applicants – unless, that is, the Federal government decides that the information may no longer be required.
2. Although it would be a major step forward to give State health agencies some access to State and Federal tax data, it will not be a panacea:
a. Medicaid income eligibility is determined on a person-by-person basis, and we must determine, for each person, whose income is attributable to him or her. In some cases ‘Medicaid income’ relevant to an applicant (e.g., the child of an unmarried cohabiting couple) will not match up with the income reported on any one person’s tax return.
b. Medicaid eligibility will continue to be determined “as of the point in time an application is processed,” Section 2002(a) (amending 42 U.S.C. 1396a(e)(14)(H)), which means that for many applicants, Medicaid will need to collect midyear income data, and will not be able to rely on tax return data.
c. Not everyone files tax returns.
What follows is a broader list of some of the major complicating factors in the Medicaid eligibility world — and questions about what might be done to reduce complication. Discussion of some of the provisions of PPACA is woven through the list.
We are also attaching a pdf of our current online application for medical benefits so that you will have at least one concrete example to review.
Finally, before proceeding to our detailed list, we wish to voice an overriding concern, which we are sure is shared by many other states: we strongly endorse the statutory goal of an eligibility system in which databases can automatically pull together most of the information required to make eligibility determinations. But building such a system, in Oregon as in other states, will require a dramatic investment in new and improved information technology. Especially in light of our grave State budget situation, which, unfortunately, shows no signs of improving in the near future, we will be heavily dependent on Federal assistance to make the necessary technology investments.
DHS relies on over 37 aging, disparate systems to support client eligibility and issue benefits. These systems range in age from 18 to over 30 years old and were built at a time when, for example, SNAP benefits were issued to approximately 200,000 Oregonians; today, over 600,000 Oregonians receive SNAP benefits monthly. Many of these systems utilize aging technology that is difficult to maintain and sustain. Systems have myriad interfaces to other systems at DHS, resulting in a technical environment which is not conducive to making timely, efficient changes in response to federal or state mandates and to support caseworker or client needs. Caseworkers enter the same data multiple times into different systems and information is not readily shared between systems. Reporting is extremely challenging in this environment.
1. Issues in collecting income information
Wage income
People whose only income is wages from employers should be the easiest people to income-verify. But right now clients and caseworkers spend a lot of time collecting and waiting for pay stubs to demonstrate income. There is one group of people largely immune from the Pay Stub Shuffle: those whose employers are on the Work Number system, used by many large employers, which has up-to-date and comprehensive pay information. Our caseworkers can use Work Number to look up a client’s wage income – but only for those employers that participate in Work Number, which is far from all of them.
How could we put an end to the Pay Stub Shuffle?
The Federal government could require and assist every employer to participate in a program equivalent to Work Number. (Ideally, this would be a free Federal service; Work Number itself requires states to pay for information, and employers, too, need to pay to participate.)
States could decide to use, and the Federal government could endorse using, slightly outdated Employment Department information.
State Medicaid programs generally have access to their state Employment Departments’ quarterly payroll data. One problem with using information that is at all outdated is that people can get poorer quickly; if you rely on older data, you might turn down some people who are in fact eligible. (See below for more on this topic.)
States could decide to base eligibility decisions, for Medicaid as well as the Exchanges, on the income information in last year’s tax return, and either the Feds or State Revenue Departments could make tax returns available to State Medicaid agencies and Exchanges.
Given that PPACA says that we are going to have to base eligibility decisions on Modified Adjusted Gross Income, and that Medicaid and Exchange offices will be linked to databases that include tax return information, it would make sense to start to tie eligibility determinations to tax forms. However, this will not always work for Medicaid, because a Medicaid ‘application income group’ will not always be the same as a tax filing group. An unmarried couple with a child, living together, will generally not file taxes together, but their income would be combined in a Medicaid eligibility determination for their child. For that matter, even a married couple with a child may choose to file taxes separately, but their income would be combined in a Medicaid eligibility determination for that child.
Unless the Federal government plans to change the rules so that Medicaid eligibility income groups are equivalent to tax filing groups, tax return information will be of limited use for Medicaid – certainly useful, but not a cure-all.
Even to the extent ‘tax filing groups’ do line up with ‘Medicaid eligibility income groups,’ there’s another problem: as noted above, Medicaid eligibility will continue to be determined “as of the point in time an application is processed” – in other words, based on current income. So States will not generally be able to base eligibility decisions made in, say, August on tax return information for the previous year
See below for additional questions about reliance on tax return information.
Non-wage income – verifiable
There are some sources of nonwage income that are fairly readily verifiable. We can collect information on unemployment, Social Security payments, child support payments pretty much ASAP.
However, right now our workers have to look at separate screens to retrieve each piece of information. We could use (and would very much appreciate) federal assistance to help pay for technology solutions to retrieve wage and non-wage related data in other agencies’ systems and automatically populate that information into the medical eligibility determination system.
Non-wage income – hard to verify
There are certain categories of nonwage income that are harder to verify, such as rental property income, private pension income, and especially self-employment income. The income of the self-employed is not kept in any up-to-date database. And again, even if this information is available on an annual basis through tax forms, to the extent we are basing eligibility decisions on current income, tax forms will not always help.
We would appreciate suggestions from other states, and guidance from the Workgroup, on how to simplify collection and verification of this income information.
2. Collecting citizenship information
Clients and caseworkers now spend some of their time collecting and waiting for out-of-state birth certificates. SSA and the States are making progress toward verifying citizenship, in many cases, through SSA, rather than through birth certificates. However, unless and until we reach the point that SSA records can completely replace birth certificates as a means of citizenship verification, we would urge the Federal government to assist the States in developing a national birth certificate database.
3. Collecting absent parent information – a complication that may disappear?
Oregon, like other States, requires applicants to identify and provide information on ‘absent parents’ as part of the application process. This is another complicating factor – applicants need to fill out the information ‘by hand’ as it were; they can’t just refer caseworkers to the ‘absent parent database.’ We ask the Work Group to keep this fact in mind.
It seems possible, however, that PPACA has implicitly eliminated this complication. Section 1411(g)(1) says: “An applicant for insurance coverage or for a premium tax credit or cost-sharing reduction shall be required to provide only the information strictly necessary to authenticate identity, determine eligibility, and determine the amount of the credit or reduction.”
We think this provision could be read as prohibiting States from continuing to ask absent-parent questions; although States have generally treated cooperation with such inquiries as a prerequisite to eligibility, we can imagine an argument that such information is not “strictly necessary …” We ask the Work Group’s assistance in seeking clarification of this point.
4. Further questions about access to and reliance on tax return data
As stated above, ‘shared income groups’ for purposes of Medicaid applications will not always line up with tax filing groups. This will limit States’ ability to rely on tax returns in Medicaid eligibility determinations, unless – again – the Federal government plans to change the rules so that Medicaid eligibility income groups are equivalent to tax filing groups. We ask the Workgroup whether such a change in the rules is under discussion.
We also have some additional questions about the link between tax data and health agencies envisioned under PPACA:
Ideally, Medicaid agencies would have access to tax data which included MAGI. However, it does not seem that the IRS is going to make tax returns, or calculations of MAGI, directly available to State health agencies. The statute seems to envision verification by the IRS of information transmitted to the IRS by HHS (after HHS gets it from the States); that seems quite different from the IRS just sending us the information.
Specifically, Section 1414(a) says that Treasury may share filing status, number of dependents, and MAGI with HHS, and HHS may share with State agencies “any inconsistency between the information provided by the Exchange or State agency to the Secretary and the information provided to the Secretary” by Treasury. Based on that language, it’s not clear to us that States can get anything out of the IRS except, “Your applicant is lying to you.” It appears that the States will still be responsible for collecting income information, in the first instance, from applicants or from non-IRS databases. Is that the Work Group’s understanding?
Theoretically State tax departments could make data from applicants’ returns available to State health departments. MAGI does not appear as a line item on State returns. However, Oregon Department of Revenue does ask taxpayers to submit a copy of the Federal return, from which MAGI can be derived. Not all taxpayers comply, however. The only way the Oregon Department of Revenue could absolutely ensure that MAGI were on State tax returns would be to add questions about the elements of MAGI (tax exempt interest, foreign earned income and housing costs) to the basic State tax form.
How does the Workgroup think the process of extracting MAGI information from tax returns is supposed to work?
Importantly, does the Workgroup anticipate that the Federal government will provide States the funds needed for the technology advances necessary to allow State Revenue Departments to transmit the needed information smoothly to Medicaid offices?
Finally, we think it important to note that some people simply do not file tax returns, so the availability of tax return data will never solve all of our income-verification problems.
5. Possible tensions between the “single portal/no wrong door” policy and the goal of simplicity and streamlining
Section 1413 of PPACA envisions that applicants to participate in any “health subsidy program[]” (including both Medicaid and Exchanges) shall be able to submit a “single, streamlined form … to apply for all applicable health subsidy programs within the State” (1413(b)(1)()A)(i), and that such an applicant “shall receive notice of eligibility for an applicable State health subsidy without any need to provide additional information or paperwork unless … [the information] is otherwise insufficient to determine eligibility.” Although “is otherwise insufficient to determine eligibility” is a big exception, the obvious goal is to have a simple form that allows for determination of eligibility for any medical program.
There are potential tensions between the two noble goals of having “no wrong door” and a “streamlined system.” For example:
1. For purposes of determining eligibility for a tax credit from Exchanges, an applicant might just have to submit income information as reported on a previous tax return for a full year. But for purposes of a Medicaid eligibility determination, he/ she / they would have to submit updated information on current income. To fulfill the ‘no wrong door’ goal, the ‘streamlined’ form would have to request both.
2. For purposes of determining for a tax credit from Exchanges, an unmarried applicant living with the mother of his child would have to submit his own income information as reported on a previous tax return for a full year. But for purposes of a Medicaid eligibility determination for that child, the unmarried applicant would also have to report the mother’s income – unless, again, the Federal government changes the rules to synchronize tax filing groups and Medicaid ‘income eligibility’ groups.
We recognize that the resolution of this tension may not fall within the scope of the Workgroup’s responsibilities, but it is relevant to the goal, which the Workgroup referenced in its request for comments, of “mak[ing] applying for health insurance and other human service programs as easy as using the Internet to pay your bills or file your income taxes.”
6. The existence of numerous eligibility categories
One of the issues that makes Medicaid eligibility arguably more complicated than income taxes is that whereas in the case of income taxes, one filing group submits a tax return and is treated consistently as one filing group, in the Medicaid context, generally speaking, a household submits an application listing everyone in the household, and then caseworkers look through the application to see, for each member of the household, into which of a number of eligibility categories that person might fit. To give the most basic example, each member of a household might be found ineligible for Medicaid, but one child in the household might be eligible for CHIP.
The sheer number of eligibility categories, plus the person-by-person analysis Medicaid requires, plus the fact that different Federal match rates apply to different eligibility categories, are major complicating factors in our world. We are not sure to what extent PPACA relieves these complications. For example, the fact that States will receive an enhanced match for ‘new eligibles’ seems to imply that we will have to continue to examine new applicants through the lens of the myriad ‘old’ eligibility categories, in order to determine if we can take advantage of the enhanced match rate for those applicants.
Question: To what extent does the Workgroup believe that PPACA has implicitly or explicitly reduced the number of Medicaid eligibility categories?
We are currently moving toward a technology solution that will support our caseworkers by providing automated assistance in making these complex eligibility determinations. We could certainly use some Federal financial assistance in that effort.
7. Differences between information required for Medicaid and for other human service programs
Your request for comments says:
What we critically need—and what these standards have the promise to support—is an eligibility and enrollment system that will make applying for health insurance and other human service programs as easy as using the Internet to pay your bills or file your income taxes. It should be possible to apply for programs online, easily obtain the documents and information needed to confirm eligibility, and re-use this information to apply for a variety of programs, and re-certify your eligibility when the time comes.
Our reading of PPACA is that the law itself might make reaching the goal of simultaneously applying for health programs and other human service programs a bit tricky. As noted above, Section 1411(g)(1) says:
“An applicant for insurance coverage or for a premium tax credit or cost-sharing reduction shall be required to provide only the information strictly necessary to authenticate identity, determine eligibility, and determine the amount of the credit or reduction.”
So, to the extent that SNAP, TANF or other programs require information different from what the health coverage application requires, 1411(g)(1) does not allow us to require that information on health coverage applications.
And it is definitely the case that other programs require information different from that required by health programs. For example, SNAP asks an assortment of questions about housing and utility costs which Medicaid does not ask.
Perhaps the way to reconcile the goals of a simple process to apply for a variety of programs with the language of 1411(g)(1) is for States – or the Secretary of HHS, in the “single, streamlined form” envisioned in section 1413(b)(1)(A) – to have an application section entitled something like, “Supplemental Questions If You Want to Be Considered for Other Human Services Programs.”
We are currently moving toward an interactive, online application process for clients, and it has been our goal to set up the process to collect all the information relevant to determining eligibility for a variety of programs. As we proceed, we will have a better idea of how much conflict – if any – there is between that goal and the restriction imposed by 1411(g)(1). We encourage you to explore this issue with other states that have already implemented such interactive online applications.
8. A database option for asset information. For long-term care Medicaid clients, we need to request asset information as of the date of the application (we generally request at least the most recent bank statement), plus information on resource transfers for the previous 60 months (we may simply take the client’s word on that issue). One way to replace “paper and promises” with database information on assets would be to give all Medicaid offices the ability to access a network of banks. Right now vendors such as Acuity and HMS provide such access, for a price; ideally, there would be a free Federal service providing such access.
Thank you very much for considering these comments.
Agree or Disagree:
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