Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program August 2007 Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: Catherine Teare, M.P.P., Len Finocchio, Dr.P.H., Victoria Martin-Young, M.P.H. August 2007 Acknowledgments The authors would like to thank the individuals who reviewed this evaluation and offered their expertise: Sandra Shewry, Stan Rosenstein, Marian Dalsey, M.D., Harvey Fry, Maggie Petersen, Christy Quinlan, Marlene Ratner, and Lisa Trujillo-Dunn, California Department of Health Care Services; Beth Morrow and Kristen Golden Testa, The Children’s Partnership; Sam Karp and Ingrid Aguirre-Happoldt, California HealthCare Foundation; Lynn Kersey and Lucy Quacinella, Maternal and Child Health Access; Caroline Davis and Claudia Page, The Center to Promote HealthCare Access. Jina Wang of the California Department of Health Care Services provided invaluable assistance with CHDP Gateway and Medi-Cal data. About the Authors Catherine Teare, M.P.P., and Victoria Martin Young, M.P.H., are independent health policy researchers and consultants. Len Finocchio, Dr.P.H. is a senior program officer at the California HealthCare Foundation. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information about CHCF, visit us at www.chcf.org. ISBN 1-933795-36-0 © 2007 California HealthCare Foundation Contents 4 Executive Summary Data Analysis Highlights Findings Improving the CHDP Gateway Methodology 7 I. Introduction Methodology 9 II. Background: Development of the CHDP Gateway CHDP Gateway Goals 13 III. CHDP Gateway Performance by the Numbers Demographics Pre-Enrollment Joint Application and Follow-Up Eligibility Determination 16 IV. Discussion: Gateway Successes and Challenges A. Pre-Enrollment and Temporary Coverage B. Enrollment in Continuous Coverage C. Automatic Newborn Enrollment 22 V. Recommendations for Improving the CHDP Gateway Training, Coordination and Outreach Interim Technological Solutions Looking Toward the Future: Moving Children into Continuous Coverage Conclusion 27 Appendix A: CHDP Gateway Data Elements and Analytical Findings 29 Appendix B: Elements of the Gateway Process 33 Endnotes Executive Summary IN 2003, THE CHILD HEALTH AND DISABILITY Prevention (CHDP) Gateway debuted as California’s largest effort to enroll children in health insurance coverage through their health providers’ offices. The Gateway is an automated process that has two primary goals: (1) to pre-enroll children into temporary, full-scope Medi-Cal coverage after a CHDP health assessment; and (2) to facil- itate longer-term enrollment in the Medi-Cal and Healthy Families programs through a follow-up paper application. Three years into the program, it is important to know how well it is working. The California HealthCare Foundation funded research to: (1) look at the program’s performance; (2) identify its successes and challenges; and (3) make recommendations for improvement. Although the CHDP Gateway is succeeding in its first goal—pre- enrolling children into temporary, full-scope Medi-Cal and Healthy Families, it has been far less successful in its second goal—linking children to continuous coverage. Data Analysis Highlights Key findings: I Approximately 600,000 children were pre-enrolled in temporary Medi-Cal through the CHDP Gateway in one year. I In more than 90 percent of pre-enrollments, families requested a joint application for Medi-Cal and Healthy Families, but fewer than 20 percent returned them in time to have their children’s temporary eligibility extended. I Denial rates for continuous coverage were high, mostly because of a “failure to cooperate” with follow-up requests for information. I Approximately 75,000 Gateway children gained continuous Medi-Cal or Healthy Families coverage. This represents 11 percent of pre-enrollees, or one in nine, gaining long-term full-scope Medi-Cal or Healthy Families coverage through the Gateway. The rate rises to 12 percent when children with continuous limited-scope Medi-Cal are included. I Approximately 64,000 children under age one were automatically “deemed eligible” for full-scope Medi-Cal continuously until age one during the study year. 4 | CALIFORNIA HEALTHCARE FOUNDATION Findings I It is difficult to thoroughly assess the Gateway’s Interviews, site visits, analysis of program data, success in enrolling children in continuous cov- and focus group findings were used to evaluate erage when their eligibility status is unknown. Gateway’s successes and identify challenges for I Not all CHDP providers have the commit- specific Gateway components and processes. ment, resources, and motivation to assist fami- The findings include: lies in gaining long-term coverage for their children. High turnover among office staff Pre-enrollment and temporary coverage compromises Gateway’s functioning. I A large proportion of the uninsured children in I Assistance in completing the application is California are receiving health assessments important, but few families receive follow-up through the CHDP program and temporary assistance from providers or local CHDP staff. coverage through the CHDP Gateway link to Medi-Cal. Automatic newborn enrollment I Children are receiving care with their tempo- I The system has not yet succeeded in systemati- rary Medi-Cal coverage that they would not cally identifying and successfully enrolling all previously have accessed, though gaps remain. newborns who are “deemed eligible” for con- I The Gateway’s file clearance system is fast and tinuous, full-scope Medi-Cal. efficient. Providers, CHDP staff, and other I Providers’ knowledge of enrollment policies observers were generally satisfied with the and procedures for newborns is limited. Gateway’s functioning. The CHDP Gateway’s automatic file clearance system represents a sig- Improving the CHDP Gateway nificant improvement in enrolling children in This report identifies 12 steps for improving the health insurance, but has a number of impor- CHDP Gateway. They are: tant problems. I Most problems with the Gateway’s file clear- 1. Reevaluate and extend standardized training ance are intrinsic to an automated system on Gateway function and use. working with a large and complex database. 2. Intensify CDHS and county efforts to iden- Imperfect or missed matches may lead to the tify and resolve Gateway-initiated enrollment creation of duplicate files for the same child, problems. causing problems for families, providers, and 3. Provide all families with application assistance. eligibility workers. 4. Connect eligible children with county Enrollment in continuous coverage Healthy Kids programs. I Requiring families to submit a separate, new 5. Discontinue the practice of sending a Benefits application to receive continuous Medi-Cal Identification Card (BIC) to children with or Healthy Families coverage impedes follow- temporary coverage. through and is the weak link in the Gateway 6. Pre-populate the paper application sent to process. families with information provided during the I Families of eligible children fail to apply for pre-enrollment screening, including the child’s longer-term coverage for many reasons, includ- BIC number. ing lack of understanding of the process, per- 7. Continue to evaluate and improve the auto- ception that temporary coverage is sufficient, matic file clearance technology. and need for assistance in completing the application, among others. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 5 8. Simplify underlying eligibility rules for Medi- Cal and Healthy Families. 9. Allow the Gateway application to serve as a Medi-Cal application. 10.Adopt a cross-cutting approach to enrollment. 11. Prioritize the development of a replacement system for the Medi-Cal Eligibility Data System (MEDS). 12.Expand eligibility to all children. Methodology Research activities included analysis of Gateway enrollment data, interviews with more than 50 stakeholders across California, eight provider site visits in three counties, and an extensive review of documents. Interviews and visits occurred between January and May, 2006. In addition, The California Endowment commissioned 12 focus groups, which were conducted to obtain qualitative information from parents of children who had recently passed through the Gateway, providers who enroll families in the Gateway, and local CHDP staff. These were held in January and February, 2006, in Sacramento, Los Angeles, Fresno, and San Bernardino counties. The California Department of Health Services (CDHS) and the Managed Risk Medical Insurance Board (MRMIB) provided quantitative data on pre-enrollment through the CHDP Gateway and on eventual enrollment in continu- ous Medi-Cal and Healthy Families coverage for the year ending September 30, 2006. 6 | CALIFORNIA HEALTHCARE FOUNDATION I. Introduction IN 2003, THE CHILD HEALTH AND DISABILITY Prevention (CHDP) Gateway debuted as California’s largest effort to enroll children in health insurance coverage through their health providers’ offices. The Gateway is an automated process with two primary goals: 1) to pre-enroll children into temporary full-scope Medi-Cal coverage after a CHDP health assessment; and 2) to facilitate continued enrollment in the Medi-Cal and Healthy Families programs through a follow-up paper application. Three years into the program, the California HealthCare Foundation funded research to: (1) look at the program’s per- formance; (2) identify its successes and challenges; and (3) make recommendations for improvement. Methodology The researchers conducted semi-structured interviews with more than 50 stakeholders across the state. Interviewees included: CHDP and other health department staff at the state and local levels; county officials; CHDP providers and repre- sentatives of provider organizations; advocates; legislative staff; and others. Researchers visited eight provider sites in three counties and observed the Gateway screening and enrollment processes directly. The interviews and site visits took place between January and May, 2006. In addition, researchers examined published Gateway materi- als, including CHDP Provider Information Notices, All County Welfare Directors Letters, and provider manuals. Descriptions of the intake and electronic interface were taken from interviews and observations, as well as from the Gateway Internet Step-by-Step User Guide (June 2004).1 The researchers reviewed extensive data from the California Department of Health Services (CDHS) and the Managed Risk Medical Insurance Board (MRMIB). Appendix A includes detail on the data elements used and their limitations. CDHS staff assisted us with data analysis and review through conference calls, email correspondence, and meetings. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 7 In a related project, The California Endowment commissioned focus groups by Lake Research Partners (LRP) to solicit the opinions and experi- ences of parents of children who had recently passed through the Gateway, providers who enroll families in the Gateway, and local CHDP staff. Twelve focus groups were held in January and February, 2006, in Sacramento, Los Angeles, Fresno, and San Bernardino. Some information from these focus groups is included in this report; the full report is available at www.calendow.org/ reference/publications/pdf/access/CHDP% 20Gateway.pdf. 8 | CALIFORNIA HEALTHCARE FOUNDATION II. Background: Development of the CHDP Gateway SINCE 1973, CHDP HAS SERVED CALIFORNIA children, especially those ineligible for Medi-Cal due to family structure or income. CHDP paid for approximately 2 million health assessments each year, both for children enrolled in Medi-Cal (for whom CHDP provided the “screening” portion of the federally mandated Early and Periodic Screening, Diagnosis and Treatment [EPSDT] Medicaid benefit), and for uninsured children. (See the box on page 11 for detail on the CHDP program.) If a CHDP visit revealed that a Medi-Cal enrolled child had a medical condition or illness requiring treatment, Medi-Cal paid for the diagnosis and treatment of the condition, as required by EPSDT. As a condition of receiving Proposition 99 funding, counties were required to provide medically necessary follow-up and treatment for uninsured children. Unfortunately, many uninsured children failed to receive it.2 In the late 1990s, the State Children’s Health Insurance Program (SCHIP)3, implemented in California as Healthy Families, made children with family income up to 250 percent of the Federal Poverty Level eligible for comprehensive cover- age. Simplifications to Medi-Cal eased access to that program for some children.4 As a result, some of the children traditional- ly served by CHDP were now eligible for Medi-Cal or Healthy Families, and families’ continued reliance on CHDP used state dollars when federal matching funds were available in the other programs. Therefore, CDHS encouraged the CHDP program to operate as a “gateway” to insurance coverage, but did not implement specific technologies or policies—or provide fund- ing—to accomplish the task. In 2001, the Legislative Analyst’s Office (LAO) released a report criticizing the gateway function of CHDP as a failure, and recommended system and program improvements.5 It rec- ommended creating a “Model Gateway” designed to encourage enrollment in Healthy Families and Medi-Cal, and called for a significant upgrade of the information systems at CHDP, Medi- Cal, and Healthy Families information systems to allow tracking of children’s applications and billing across programs.6 In the wake of this report, and citing significant General Fund savings, then-Governor Gray Davis recommended the complete elimina- tion of the CHDP program in the FY 2002 budget. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 9 This recommendation was immediately and serve as an application for Medi-Cal, thereby forcefully opposed by a wide range of stakehold- eliminating the need for a paper follow-up appli- ers. Citing CHDP’s role as a funder of primary cation. SB 43710 directs CDHS to develop an care for uninsured children and as a public health “automated enrollment gateway system” allowing player, along with its potential as a site for enroll- children applying to the Women, Infants and ment, they proposed that an electronic “gateway” Children (WIC) program to simultaneously be developed to increase enrollment in Medi-Cal obtain presumptive eligibility for Medi-Cal or and Healthy Families while continuing to serve Healthy Families and apply for long-term enroll- children who do not qualify for those programs. ment in one of the health insurance programs. Furthermore, SB 24, passed in 2003, requires The CHDP Gateway, which was rolled out in two provider-based electronic gateways to Medi- 2003, enrolls children in temporary full-scope Cal for newborns and pregnant women. The Medi-Cal coverage and facilitates enrollment in CHDP Gateway mechanism has been identified Medi-Cal and Healthy Families by sending a as a possible infrastructure for these new elec- paper application to families who express interest tronic means to enrollment. in long-term coverage. In 2004, the Gateway procedures were amended to account for new- borns whose mothers had Medi-Cal at the time CHDP Gateway Goals of delivery and who are “deemed” eligible for The CHDP Gateway has two primary goals: (1) coverage. pre-enrolling children in temporary Medi-Cal at By enrolling children in temporary Medi-Cal the time of CHDP health assessments; and (2) coverage, California has been able to draw upon facilitating the enrollment of eligible children in federal dollars for CHDP screenings and immu- continuous coverage. Its electronic interface with nizations, as well as for all follow-up care during the Medi-Cal Eligibility Data System (MEDS)11 the temporary coverage period. Significantly, this permits near—instantaneous transactions, temporary Medi-Cal coverage is provided to chil- including eligibility determination and enroll- dren presumed eligible solely on the basis of age ment in temporary coverage. The overall and family income; immigration status is not Gateway design includes not only the electronic considered. Later, they may be found not to interface, but also policies and procedures on pre- meet all eligibility requirements for continued enrollment and temporary coverage, the process full-scope coverage. In some cases, their families for extending coverage and submitting a full may decide not to apply for continuous coverage. application, and final eligibility determination. Before Gateway implementation, most of these The four basic elements of the Gateway process services were paid for with state dollars, without are described briefly here, illustrated in Figure 1, federal matching funds. As a result of the and described in detail in Appendix B. Gateway, state funding for the CHDP program declined from a high of approximately $129 mil- I Intake and electronic interface. An unin- lion in 2001–02 to an estimated $4.2 million in sured child arrives for health care at a CHDP FY 2004–05.7 The Governor’s budget proposal provider’s office, and his/her family completes for FY 2006–07 allotted only $3.7 million ($3.6 a brief CHDP Gateway pre-enrollment appli- million from the General Fund) for the program.8 cation that is available in 11 languages. The provider enters the information from the The Gateway will soon change in response to family’s completed pre-enrollment application legislation passed in 2006. AB 19489 directs on the CHDP Gateway’s screens, and the CDHS to study the feasibility of modifying the Gateway links electronically to MEDS to existing Gateway electronic application to also determine the child’s eligibility for pre-enroll- 10 | CALIFORNIA HEALTHCARE FOUNDATION California’s Child Health and Disability Prevention (CHDP) Program I CHDP provides the screening and diagnosis I Other services offered through the program portion of the federal Early and Periodic include: Screening, Diagnosis and Treatment (EPSDT) G Health and developmental history; benefit, a Medicaid benefit for children up to G Oral, nutritional, and behavioral health age 21.* In California, CHDP incorporates the assessments; preventive screenings, immunizations and G Immunizations; assistance with scheduling and transporta- tion that EPSDT requires. Children who G Health education and anticipatory require additional services are referred either guidance; and to a provider in the Medi-Cal program or to G Referral for needed diagnosis and another provider that has agreed to accept treatment. CHDP referrals. I The CHDP fee-for-service periodicity sched- I Children eligible for CHDP services include: ule provides for one health assessment at G Children under the age of 21 enrolled in each of the following ages: Medi-Cal; and G Less than 1 month G Children under the age of 19 in families G 2 months with income at or below 200 percent of G 4 months the federal poverty level ($33,200 for a G 6 months family of three in 2006) and residing in G 9 months California. G 12 months I The CHDP program is administered by the G 15 months California Department of Health Services G 18 months (CDHS), which provides general oversight G 2 years and pays providers, and implemented by G 3 years local county and city health departments, G 4–5 years which are responsible for recruiting CHDP G 6–8 years providers, ensuring provider outreach and G 9–12 years education, and handling referrals and follow- G 13–16 years up visits for clients. G 17–20 years I The health assessment that is the center- * Source: California Department of Health Services. Child Health and Disability Prevention Program. piece of the CHDP program encompasses a “Program Overview: What Services Does CHDP complete physical exam, vision and hearing Provide?” http://www.dhs.ca.gov/pcfh/cms/chdp/ screening, immunizations, and lab screening. ment in temporary, full-scope Medi-Cal. As Medi-Cal or Healthy Families benefits has not part of the screening, the family is asked been determined; and (3) another complete whether they wish to apply for long-term cov- application is required to complete the full eli- erage through Medi-Cal or Healthy Families. gibility determination process. I Pre-enrollment and temporary coverage. The I Joint application and application follow-up. Gateway screening process creates a record on If the family requested an application for long- MEDS. The child leaves the CHDP provider’s term coverage at the time of the health assess- office with documentation of temporary full- ment, they receive a joint Medi-Cal/Healthy scope Medi-Cal coverage, also known as an Families application in the mail, with instruc- “immediate need document.” This process is tions to complete it and return it to the Single called “pre-enrollment” because: (1) the cover- Point of Entry (SPE) processing center. age is temporary; (2) eligibility for long-term Applications are also available at CHDP providers’ offices. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 11 I Eligibility determination for continuous full- There are different rules for infants, who are scope coverage. If the family mails the applica- “deemed eligible” for Medi-Cal coverage until tion before their child’s temporary Medi-Cal their first birthday, if they are born to women coverage period ends (or submits an applica- who were covered by Medi-Cal at the time of tion through any other channel), coverage is delivery. The Gateway is designed to identify and extended until a final eligibility determination automatically enroll these children in full-scope is made. If the family does not return an appli- Medi-Cal until their first birthday, bypassing the cation in time, the child’s coverage terminates second enrollment step of the paper application. at the end of the temporary coverage period. Figure 1. Flowchart of CHDP Gateway Enrollment Processes Intake and Electronic Interface If family decides not to receive joint application they are still eligible for CHDP Child is in MEDS exam and temporary full system and is scope Medi-Cal for 60 days. CHDP Visit already covered by Medi-Cal/Healthy Families; Family decides to Provider uses Family arrives at Family receives a apply for continuous Provider electronic applica- provider’s office or “Pre-Visit” Medi-Cal or Healthy electronically Child is eligible for a tion, based on CDHS community clinic brochure explaining Families coverage screens child to CHDP exam; or 4073, to screen for a CHDP exam. Gateway process. and agrees to determine if: child’s eligibility receive joint through the Internet application in the or POS device. mail. Child is eligible for temporary full Application and Follow-up Pre-enrollment and Temporary Coverage scope Medi-Cal for 60 days, also Family reviews CDHS sends CDHS mails client Client is mailed a known as the Exam Family receives application for client a 15-day joint Medi-Cal/ Benefits ID Card “pre-enrollment” Conducted “immediate accuracy. Provider reminder Healthy Families (BIC) within a period. need” document. transmits applica- notice if application. week. tion electronically. application not returned. Local counties receive list of clients requesting joint application. Healthy Eligibility Determination Families Local counties processes Child is continu- follow up with application. Client mails SPE routes ously covered clients who Client receives completed application to through Medi-Cal requested an letter confirming application to Medi-Cal or or Healthy application but that application SPE. Healthy Families. Families; or have not was received. submitted it to Pre-enrollment period is extended. County SPE. processes Local CHDP Medi-Cal If denied by Local CHDP Gateway application. Medi-Cal or Gateway partners provide Healthy Families, partners can application pre-enrollment assist in finding assistance. period is other health terminated. coverage. Source: Alameda County CHDP Gateway Flowchart 12 | CALIFORNIA HEALTHCARE FOUNDATION III. CHDP Gateway Performance by the Numbers HOW WELL DOES THE CHDP GATEWAY MEET its goals of pre-enrolling children in temporary Medi-Cal and facilitating enrollment in continuous coverage? Much can be seen from the data. This analysis examined enrollment and utilization data from CDHS and the Managed Risk Medical Insurance Board (MRMIB) to evaluate the Gateway’s performance on a variety of different measures. The CDHS Information and Technology Support Division (ITSD) provided demographic and enrollment data for the period October 1, 2005, through September 30, 2006. MRMIB’s “CHDP Gateway Initiated Applications Statistics”12 for the same period was analyzed for data on Gateway applications processed by the Single Point of Entry. Except where noted, information in this section is from the most recent CDHS data. Appendix A provides detailed descriptions of the data elements used for this analysis. Demographics More than one-third of the approximately 600,000 children who went through the CHDP Gateway in 2005–2006 were under the age of one. Another third were between the ages of one and six. Figure 2. CHDP Enrollment by Age 16% Less than 1 year Ages 1 through 5 years Ages 6 through 11 years 35% Ages 12 through 18 years 17% 32% Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 13 Five Southern California counties account for respectively). However, only 18 percent of these almost two-thirds of children pre-enrolling applications were returned (on behalf of 109,287 through the Gateway: Los Angeles (34 percent), children) within the temporary eligibility period. Orange (9 percent), San Diego (8 percent), and Applications were returned for a total of San Bernardino and Riverside (7 percent each). 155,595 children within 90 days of initial Spanish was the language “read best” by two- application, meaning that nearly 50,000 chil- thirds (66 percent) of the families whose chil- dren may have experienced interruptions in dren passed through the Gateway. Almost all coverage because their parents returned the the remaining families (30 percent) listed application too late to have their temporary English as the language they read best, with Medi-Cal eligibility extended. only 4 percent of pre-enrollees naming other The number of applications returned include primary languages.13 joint applications returned to the Single Point of Entry (SPE), and those returned through other Pre-Enrollment avenues (county offices, CAAs, etc.). According More than 600,000 (613,575) children passed to CDHS staff, “most” of those applications through the CHDP Gateway and pre-enrolled in come through SPE. MRMIB reports that SPE temporary Medi-Cal (or were infants deemed eli- processed applications on behalf of 102,407 gible for coverage) from October 1, 2005, to CHDP Gateway-enrolled children from October September 30, 2006. Most of these children 2005 through September 2006.15 (535,741) pre-enrolled only once in that period, but 13 percent of them pre-enrolled two or more Eligibility Determination times. The total number of pre-enrollments dur- Enrollments. Nearly 70,000 children (67,539) ing the period studied was 712,755. who went through the Gateway during the year The count of children passing through the studied were enrolled into full-scope Medi-Cal or Gateway represents unduplicated Client Index Healthy Families. An additional 7,988 children Numbers, or CINs. The number almost certainly were enrolled in limited-scope Medi-Cal. Thus, a includes some duplicate CINs (more than one total of 75,527 Gateway-processed children were CIN attached to the same individual). No study enrolled in continuous coverage (full- or limited- has been conducted of the duplication rate for scope). CHDP Gateway CINs, but a study of MEDS Denials. More than 50,000 pre-enrolled children overall estimated a duplication rate of 5 percent.14 who submitted joint applications were denied If that rate is accurate for CHDP Gateway full-scope Medi-Cal during the study period, pre-enrollees, the actual unduplicated count of most due to “failure to cooperate” with follow-up children pre-enrolling would be approximately requests for information. Of the applications 583,000. screened via Healthy Families, 62 percent were denied—88 percent of those because missing Joint Application and Follow-Up information was not submitted within 20 days.16 Joint applications for continuous coverage were (In part, this very high denial rate reflects the fact requested in 551,250 cases—91 percent of the that when applications come in incomplete and 605,761 pre-enrollments in aid codes 8W and 8X SPE workers cannot determine whether they (children screened as probable no-cost Medi-Cal should be processed as Medi-Cal or Healthy eligible and probable Healthy Families eligible, Families, they are screened to Healthy Families.) 14 | CALIFORNIA HEALTHCARE FOUNDATION The data on denials suggests that many of the Pending cases. More than 6,000 cases of chil- submitted applications are incomplete. It is not dren who pre-enrolled between October, 2005, possible to identify which applications were pre- and September, 2006, in aid codes 8W and 8X pared by the family without assistance, and were still pending in December, 2006, past the which had help from certified application assis- point at which coverage should have been termi- tors (CAAs), or were submitted through county nated or a final eligibility determination made. welfare offices. This is a source of significant concern to state and local officials. Rate of enrollment in continuous coverage. About 11 percent of pre-enrollees, or one in nine, gained long-term full-scope Medi-Cal or Healthy Families coverage through the Gateway. The rate rises to 12 percent when children with limited- scope Medi-Cal are included. These rates are essentially unchanged from a year earlier,17 despite the fact that CAA funding was reinstated for the 2005–2006 fiscal year, which might have been expected to lead to both a greater number of applications and a higher percentage of complete applications. Deemed-eligible infants. Approximately 64,000 infants were “deemed eligible” for full-scope Medi-Cal until age one during the study year. Some 150,000 other infants were pre-enrolled in temporary Medi-Cal, though this figure may be exaggerated due to duplicate CINs, as discussed above. While not every child under age one could have been deemed eligible for a full year of coverage (as not all of them met the deeming conditions: (1) the mothers had Medi-Cal at the time of delivery; (2) the children had lived with their mothers during the month of birth; and (3) the children continue to live with their mothers in California), the relatively low num- ber of such infants relative to the total number of children under age one who pass through the Gateway suggests that more work is needed to identify eligible infants. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 15 IV. Discussion: Gateway Successes and Challenges “[The CHDP Program] has THE QUANTITATIVE DATA SUGGEST THAT helped me very much. There was although the Gateway successfully pre-enrolled some 600,000 a time that I didn’t have any children into temporary, full-scope Medi-Cal and Healthy insurance and the program was Families, it has been less successful as a pathway to long-term coverage. The following discussion illuminates some of the there for me to provide her shots strengths and challenges of the program highlighted by the and things for her.” research. The issues are organized into three categories: pre- —Parent of enrolled child enrollment and temporary coverage; enrollment in continuous coverage; and automatic newborn infant enrollment. A. Pre-Enrollment and Temporary Coverage A large proportion of the uninsured children in California are receiving health assessments through the CHDP program, and temporary coverage through the CHDP Gateway link to Medi-Cal. Children are receiving care with their temporary Medi-Cal coverage that they would not previously have accessed. Gaps, however, remain. CHDP screening providers are now able to treat children for medical problems identified during a screen, and to bill for this treatment. Among the services newly accessible to children are dental and vision care, pharmacy, and lab work.18 However, children are not getting all the services they might need because many parents are unaware that they can obtain pharmacy services, for example. Many parents understand that they are receiving free CHDP services on the day of the initial visit, but do not realize they are also receiving tempo- rary Medi-Cal coverage. According to CDHS, this happens because providers do not inform clients adequately, and because clients do not read or understand the documents provided to them.19 Access to services under temporary Medi-Cal is only as good as the local Medi-Cal provider network, and varies by geo- graphic region, type of provider, and other variables. For example, while some local CHDP staff and providers said that temporary Gateway coverage helped families gain access to dental and vision care, at least two counties reported that families could not find Medi-Cal dentists or vision special- ists who could see children before their temporary coverage expired. 16 | CALIFORNIA HEALTHCARE FOUNDATION “Providers love it—it gives them more nection with the MEDS system looks for a options for follow-up and treatment.” match on numerous fields. Each match or partial —County CHDP Director match is assigned points, and if the points equal or exceed 21, the system returns a match. If not, Three years into the Gateway’s operation, Medi- the system creates a new record. (See Appendix B Cal providers appear to be comfortable with its for detail on the automatic file clearance process.) immediate-need documents, both the receipt- As is typical for an automated system, the type produced by the point-of-service (POS) provider does not see the matched record (or par- device and the full-page document generated by tial match) in MEDS. This stands in contrast to the Internet interface. There were no reports of the system used by SPE and county eligibility service denial due to failure to recognize or workers, who can see multiple records in MEDS accept these documents. and can themselves approve or deny matches. The following is a discussion of specific elements Some county observers report that the Gateway’s of the pre-enrollment and temporary coverage file clearance processes have significantly process. increased duplicates in MEDS; independent observers, on the other hand, suggest that the The CHDP Gateway’s automatic file Gateway is responsible for only a portion of the clearance system duplication problem. The Gateway’s file clearance system is fast and efficient. Unlike other programs that target large Duplicate files. The MEDS database (imple- populations of eligible children, the Gateway mented between 1980 and 1983) has an estimat- indicates immediately whether a child is already ed duplication rate of 5 percent..21 The need to known to MEDS, thus minimizing future work- modernize MEDS is generally understood, but load. During the study period, 9 percent of will be difficult and expensive. A recent review of Gateway encounters ended with denials. Of these the MEDS system concluded it faces an “all but 72,725 denials, about 20,000 (28 percent) were inevitable” crisis in the near future due to the loss because children were not due for CHDP exams. of staff who can implement the required changes, Of the 52,501 coded as “other,” the majority “software entropy,” and the demand for additions were due to the child already being recognized in and changes to the software.22 the MEDS system in an aid code that makes Families filling out the CDHS 4073 may use them ineligible for temporary Medi-Cal coverage. nicknames, name variations, or may transpose Providers, CHDP staff, and other observers were last and middle names. Provider staff may trans- generally satisfied with the Gateway’s function- pose numbers when entering birthdates. In any ing. Few reported problems with either the of these cases, the result may be that records for Internet interface or the POS devices for a child with a common name may miss a match Gateway transactions. In FY 2005–06, approxi- unless all other data points are aligned. mately 60 percent of the Gateway’s transactions Duplicate files cause problems for families, (average 42,000/month) were submitted through providers, and eligibility workers. Families may the Internet interface, and more than 40 percent have their child’s coverage wrongly denied or may (average 28,000/month) through POS devices.20 encounter delays in enrollment. Duplicates may Most problems with the Gateway’s file clearance lead to providers’ claims being denied or delayed. are intrinsic to an automated system linking to a Cleaning up duplicates is time-consuming and large, complex database. The file clearance con- labor-intensive for county welfare departments. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 17 To minimize duplication and user error, CDHS Leaving aside this debate, there is general agree- has modified the file clearance process on several ment that requiring families to submit a new and occasions, adding additional fields to the file separate application to get continuous coverage is clearance match logic. In the early months of the the weak link in the Gateway process. The Gateway, CDHS recognized that some providers process works well before this point (pre-enroll- were submitting the same record repeatedly. The ments and requesting applications), and reason- Gateway has been changed to “lock” each trans- ably well after it (enrollment in continuous full- action for a day—subsequent identical transac- scope coverage for those who apply). But few tions during a 24-hour period are not processed. families take the step of returning the joint appli- cation that arrives in the mail, and even fewer do so in time to have their eligibility extended. This B. Enrollment in Continuous problem is found in other two-step enrollment Coverage programs, notably Express Enrollment.24 The low rate of successful enrollment in contin- uous coverage elicited much discussion of the Barriers to families completing the second step of Gateway’s goals. According to some stakeholders, the Gateway enrollment process were identified including architects of the Gateway, CDHS through focus groups with parents, CHDP never projected that the Gateway would result in providers, and CHDP staff, as well as from significant new enrollment in such coverage. In interviews with providers, CHDP staff, Certified this view, the Gateway was designed to bridge a Application Assisters (CAAs), and advocates. gap between screening and needed services. Some of the most important barriers include the Before the Gateway, children received CHDP following: assessments, but had very limited access to fol- low-up care, even though the counties were man- Eligibility and family perceptions I Eligibility status. Families whose children are dated to provide it. Temporary Medi-Cal cover- age through the Gateway offers far better access ineligible due to immigration status may not to services. The Gateway link to continuous cov- return the application. Reliable data on the erage was a secondary consideration, designed to eligibility status of the CHDP client popula- provide an additional entry point for families tion are lacking. According to the 2005 interested in applying. California Health Interview Survey, of the 566,000 uninsured children under age 19 and Other stakeholders maintain that continious cov- with family income under 200 percent of the erage is as central a goal of the Gateway as pre- federal poverty level in that year (roughly enrollment in temporary coverage. They point to those eligible for CHDP and the Gateway), the fact that since the program’s inception, 404,000, or 71 percent, were eligible for Gateway materials for providers and families have Medi-Cal or Healthy Families.25 prominently featured information about contin- ious coverage.23 A large number of these 400,000 eligible chil- dren may pass through the CHDP Gateway “We built a brand new, state-of-the-art high- and obtain temporary coverage. That only way, and the last two miles you have to get 75,000 Gateway children successfully enroll out and walk on a dirt road.” in long-term Medi-Cal or Healthy Families coverage suggests that Gateway’s ability to —County CHDP Director connect children to continuous coverage could be greatly improved. 18 | CALIFORNIA HEALTHCARE FOUNDATION I Poor understanding of the Gateway process. I Complex application requirements. Many Some families do not understand that coverage stakeholders complained that the application is is temporary and that they have to fill out a confusing and difficult for some people to complete application to secure continuous understand and complete without assistance.26 insurance. Many parents said they found out In focus groups, parents said that automobile that coverage had ended when they were at a and tax documentation, pay stubs, birth certifi- doctor’s office or trying to fill a prescription. cates, and social security cards were the most Almost none of the parents in the focus groups difficult documents to furnish, with birth cer- understood that the Gateway was designed to tificates often requiring long drives to retrieve. link to full-scope, continuous Medi-Cal and I Lack of application assistance. Most respon- Healthy Families. dents agreed that direct assistance with applica- I BIC is confusing. The Benefits Identification tions—from CAAs or county eligibility staff— Card (BIC) that families receive in the mail is critical to the submission of complete, shortly after their Gateway visit is the same as accurate applications. A number of CHDP the permanent eligibility card that many fami- program staff reported that they coordinate lies have had in the past. Many assume when with community-based organizations and they receive it that they have long-term cover- other sites, such as community clinics that host age and no further action is necessary. CAAs, and/or with local coalitions working on health insurance outreach. Many CHDP I Temporary coverage may be perceived as providers do not have these resources on-site. sufficient. The CHDP periodicity schedule allows nine visits by the age of two years. Provider issues Parents might therefore pre-enroll their chil- I Provider commitment and resources. Not all dren in full-scope coverage every few months CHDP providers are prepared or motivated to (as periodicity allows). One parent in Los assist families in gaining continuous coverage. Angeles said of her sick child, “We went back From some providers’ perspectives, the to the hospital. It was worth it because they Gateway is simply a new requirement for didn’t charge me anything. So I went for the doing business with the CHDP program. second time.” Some CHDP staff thought that Although all providers are expected to provide the ease and speed of the Gateway application, families with an overview of the Gateway sys- as opposed to the full Medi-Cal application, tem and direction on completing the process, was part of the attraction for families who use their performance varies. the Gateway repeatedly. From the data, this does not appear to be a common practice. I High turnover among office staff. Many Only a minority of Gateway pre-enrollees— respondents cited high levels of front-office about 13 percent—received more than one staff turnover in CHDP provider offices as a visit in the period from October, 2005, barrier to easy implementation of the Gateway. through September, 2006; more than three- Inexperienced staff were judged more likely to quarters of these children pre-enrolled twice in make data entry errors, and to have limited that year. understanding of the link to continuous cover- age. These issues were more problematic for Mail-in application and process low-volume providers. I Lag time. By the time the application arrives in the mail, families feel less compelled to complete it. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 19 I Provider training. Provider training is prima- Gateway-linked CIN, so Gateway pre-enrollees rily the responsibility of the local CHDP pro- cannot be identified as such by workers at SPE grams, and quality and frequency of training or the county. When an SPE worker receives a varies widely. Early in the Gateway’s imple- paper application, he or she follows the same mentation, CDHS provided a training curricu- file clearance procedure as for any other appli- lum and a video to local CHDP offices, and cation. In most cases, the SPE or county work- many local programs continue to use these er will locate the Gateway CIN and aid code as materials to train providers. The Medi-Cal part of a standard file clearance procedure, and website hosts a training module on Gateway will extend the child’s eligibility. However, if transactions, but that is the only training for some reason the worker locates another resource available online. CIN for the child first, then the new applica- tion will be linked to the old CIN, and the As a result of limited training resources, in child’s temporary Medi-Cal may not be many instances the responsibility for training extended. front-office staff about the Gateway rests with the providers themselves. In focus groups, In a related problem, families rarely supply a CHDP providers said that they were insuffi- child’s Social Security Number as part of the ciently prepared in terms of information and initial Gateway application. In these cases, the training, particularly when they must train system generates a pseudo-SSN that is attached their own front-office staff. However, in some to the child’s file. If the family later submits the counties, respondents reported that provider child’s true SSN; for example, on the mail-in training was “sinking in” over time, and that as application; the eligibility workers must go a result families were more aware of the fact through a confusing process to manage the two that their children’s coverage was temporary numbers properly. This issue may also lead to and that another step was necessary to ensure elevated counts of eligibility denials and of that it remains in place. pending cases.27 I Follow-up with families. Some county I Poor communication. DSS staff, advocates, CHDP programs and some CHDP providers and local CHDP staff from a number of coun- do contact families to encourage them to ties reported that communication between apply, and to offer assistance with the joint CDHS and county social services departments application, but these activities seem to be the has been poor since the program’s inception. exception rather than the rule. None of the Some county DSS staff said they do not under- parents who participated in focus groups stand clearly what happens “upstream” at the recalled any follow-up from local CHDP providers’ offices. Several had misinformation offices or from CHDP providers. about key parts of the Gateway eligibility process, despite an explanatory letter from Issues for SPE and counties. CDHS in 2003.28 A forthcoming CDHS man- Staff from Single Point of Entry (SPE) and coun- ual on file clearance will reportedly contain all ty DSS offices pointed out several problems with Gateway instructions. CHDP Gateway applications: I Linking joint application to Gateway record. Joint applications submitted for con- tinuous coverage do not include the child’s 20 | CALIFORNIA HEALTHCARE FOUNDATION C. Automatic Newborn Enrollment The CHDP Gateway enrolls more than 5,000 infants in continuing full-scope Medi-Cal every month through its “deemed eligibility” system, serving as an important back-up to hospital- and county-backed enrollment systems. However, it has not yet succeeded in systematically identify- ing all eligible infants. A major barrier is that mothers often do not have their BIC or Medi- Cal card numbers with them at the time of their newborn’s CHDP visit, and without that information the child cannot be linked to the mother’s case. Other challenges raised about the eligibility- deeming processes for infants include: I Inconsistent processes and eligibility responses. A successful transaction should deem qualified infants eligible for immediate full-scope Medi-Cal from the month of birth to age one. According to local CHDP staff, however, MEDS often erroneously sends back a temporary aid code for newborns who were believed to be deemed eligible by CHDP staff; it is unclear whether this results from incom- plete or incorrect information being submitted to MEDS through the Gateway. Consequently, some providers continue to use the older, paper Newborn Referral Form (MC 330) in addition to the CDHS 4073, faxing the MC 330 to the county welfare department.29 I Limited provider knowledge. Information about newborn enrollment does not appear to have been transmitted effectively from the state to counties, or by counties to providers. Knowledge of newborn enrollment procedures and eligibility varied widely across providers. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 21 V. Recommendations for Improving the CHDP Gateway IN THE YEAR ENDING SEPTEMBER 30, 2006, THE CHDP Gateway succeeded in providing 600,000 children with health assessments and temporary Medi-Cal coverage. The Gateway linked more than 70,000 of these children with continuous, full-scope coverage, and has the potential to become a more important piece of the enrollment system. As new entry points to coverage are implemented and eligibility for insurance is expanded, the Gateway can increase its reach and effectiveness. Across the board, people interviewed for this project supported the goals of the CHDP Gateway—from maximizing federal dollars for health care and providing immediate access to tem- porary coverage, to linking children to continuous coverage. According to one observer, the state of California “should focus on the value of continuous coverage and use the Gateway as an opportunity to get people in for an exam and then see them all the way through the process to [final] enrollment.” Many observers noted that the Gateway had become more successful over time in meeting both its goals of enrolling children in temporary coverage, and converting that coverage into long- term insurance. However, there was wide frustration with the two-step process. The 12 recommendations discussed below offer solutions to strengthen the Gateway’s performance. These are primarily directed at CDHS and MRMIB. Policy changes affecting the future of California’s overall enrollment system will require the attention of the state legislature. In addition, these rec- ommendations should inform the feasibility study for improving the CHDP Gateway required by AB 1948, and the design of the new WIC Gateway mandated by SB 437. A strengthened CHDP Gateway could serve as a model for the implementation of SB 24, which requires electronic “gate- ways” for newborns and pregnant women in hospitals and providers’ offices. Lastly, should health care reform expand eligibility for children, the Gateway will serve as a crucial entry point to coverage. 22 | CALIFORNIA HEALTHCARE FOUNDATION Training, Coordination and Outreach high or because s/he already has limited scope or Better training for providers, greater coordination emergency Medi-Cal, the system should inform between the state and county offices, and more families about county Healthy Kids or CalKids resources to support families’ application processes programs. Such connections could be made could all improve Gateway performance. through simple changes to the Gateway response messages and outreach materials. 1. Reevaluate and extend standardized train- ing on Gateway function and use. CDHS should develop online training for provider staff, Interim Technological Solutions including frequently asked questions and other Even in the absence of major changes to the sources of assistance available via the Internet, overall enrollment system, modest amendments and should evaluate the most efficient ways to could improve the Gateway’s function and the use local CHDP staff to train providers. likelihood that families will apply for continuous coverage. 2. Intensify CDHS and county efforts to iden- tify and resolve Gateway-initiated enrollment 5. Discontinue the practice of sending a problems. A forum in which state and county Benefits Identification Card (BIC) to children staff can share problems and solutions could con- with temporary coverage. These plastic cards tribute to more effective file clearance statewide. have long been a source of confusion. One Local CHDP staff should be involved to offer potential solution would be to dispense with the more guidance to their welfare agency colleagues BIC for Gateway pre-enrollees altogether. and provider staff who use the Gateway. Children would receive the permanent BIC only when they have returned the joint application 3. Provide all families with application and their eligibility has been established. In the assistance. CDHS, counties, and local net- meantime, they would use the temporary paper works should continue efforts to assist with Immediate Need Document to access services. applications. The Outreach, Enrollment, According to CDHS, only minor system changes Retention, and Utilization (OERU) county allo- would be required to accomplish this.30 For this cations for locally-driven outreach efforts were to be successful, however, some providers funded for $19.6 million in the 2006–2007 (notably pharmacists) would require additional budget. The program requires counties—working education about accepting BIC numbers on the with coalitions of community-based organiza- immediate-need documents. tions and safety-net providers—to develop and implement plans and budgets for OERU activi- 6. Pre-populate the paper application sent to ties for three years. These and other monies for families with information provided during the outreach and enrollment can be used by local pre-enrollment screening, including the child’s outreach entities to work with CHDP programs BIC number. Including the BIC number on the and providers to ensure that those with knowl- application sent to families would ensure that edge of the Gateway program and the CHDP SPE links the incoming application to the correct client population are consulted. case file, and that the child receives an extension of temporary coverage until a final eligibility 4. Connect eligible children with county determination is made. Healthy Kids programs. If the Gateway deter- mines that a child is not eligible for temporary Medi-Cal coverage because family income is too Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 23 Pre-populating the joint application with data documentation of income and residency for from the Gateway application might also encour- Medi-Cal. SB 437, passed in 2006, goes a step age more families to apply. Although the data further, requiring the state to establish a two- collected for the Gateway application is limited, phase project for self-certification of income for the receipt of a “personalized” application would Medi-Cal families. In the first phase, a two-year somewhat mitigate the two-step process, making pilot project in two counties will allow families the second step more of a follow-up. applying for or renewing coverage to certify their income. After an evaluation of the pilot, the sec- 7. Continue to evaluate and improve the auto- ond stage may include statewide implementation. matic file clearance technology. Unlike the sys- tem used at the county level or at the SPE, the 9. Allow the Gateway application to serve as a Gateway system is almost fully automated. It Medi-Cal application. There are two possible works well when accurate information is fed into approaches to streamlining, or eliminating alto- it, but automatic file clearance against the MEDS gether, the two-step application process for con- system, in an environment in which most clients tinuous coverage. An application for such cover- do not provide Social Security Numbers or other age would only be initiated at the family’s unduplicated identifiers, leads to duplicate request. The possible approaches are: records and missed matches. While these prob- A. Modified two-step option—Initiate an elec- lems are not primarily technological, program- tronic joint application with information ming changes would further improve the system’s collected at the CHDP visit. This would be functioning. CDHS says it is committed to con- sent automatically to the SPE for screening tinuing to improve the automated process as and further follow-up with the family to new insight into MEDS file clearance becomes complete the eligibility determination. The available.31 EE program offers a model whereby tem- porary eligibility is extended until the full Looking Toward the Future: Moving eligibility determination is completed. Children into Continuous Coverage B. One-step option—Offer families the option The following policy changes would create a of completing a full application at the time more efficient, streamlined, and integrated enroll- they submit the Gateway application for ment system, in which the CHDP Gateway temporary coverage. This would require could play a central role. development of a simplified application that 8. Simplify underlying eligibility rules for would collect the minimal additional infor- Medi-Cal and Healthy Families. The complexi- mation needed to serve as a full Medi-Cal ty of the joint application is a deterrent to fami- application. Since a one-step process would lies. The state will soon release an updated and require asking families about immigration simplified joint application, created with the status and collecting documentation, fami- input of county eligibility workers, CAAs, advo- lies would need to be made aware that they cates, and others. do not have to complete this stage of the application to receive temporary coverage California’s Express Enrollment (EE) Program for their children. offers a model for simplifying enrollment by allowing the school lunch application to serve as 24 | CALIFORNIA HEALTHCARE FOUNDATION AB 1948, passed in 2006, requires CDHS to increased automation and continued growth of study the feasibility of modifying the CHDP the system, in both size and complexity, demands Gateway application to eliminate the need for that MEDS improvements and/or replacement those who pre-enroll in Medi-Cal or Healthy become a priority. Any future cross-cutting com- Families to submit a second, follow-up applica- prehensive approach to enrollment will be far tion in order to remain enrolled. stronger and more efficient if MEDS is replaced. Establishing a modified two-step or a true one- 12. Expand eligibility to all children. The gov- step process in providers’ offices raises some con- ernor’s January 2007 health care reform proposal cerns. While health care providers are in many calls for expanding health insurance coverage for ways ideal enrollers, their capacity is often quite all children whose families earn up to 300 per- limited. CHDP providers experience high cent of the Federal Poverty Level. Legislative turnover in front-office staff, face great pressure efforts are pending in both the Assembly and to move patients in and out quickly, and may Senate. Evidence from Children’s Health have little understanding of the complexities of Initiative (CHI) efforts in California counties insurance programs. In addition, requiring office makes clear that an emphasis on coverage for all staff to ask questions about immigration status, children has been effective in increasing enroll- as a one-step system would, will be problematic ment efforts; the same message statewide would for staff at CHDP providers who feel that such presumably have tremendous impact on the questions jeopardize their relationships with CHDP client population. patients. Limitations on eligibility may also make the 10. Adopt a cross-cutting approach to enroll- CHDP Gateway a vital point of access. The ment. The continuing patchwork of program federal Deficit Reduction Act of 2005 (DRA) enrollment systems is inefficient and unfriendly requires U.S. citizens and nationals applying to consumers. The California Health and for Medi-Cal to show proof of citizenship or Human Services Agency should invest in a com- national status and identity. The requirement prehensive solution that facilitates more efficient does not apply to Medi-Cal’s presumptive eligi- use of existing information technologies across bility or accelerated enrollment programs, includ- agencies and programs to integrate and stream- ing the CHDP Gateway, Express Enrollment, or line enrollment and retention. A report on a the joint Healthy Families/Medi-Cal application. future enrollment system forthcoming from Children who are enrolled through these pro- Eclipse Solutions will address this approach in grams will, however, be subject to the documen- greater detail. tation requirements when their Medi-Cal status is determined (with exceptions for deemed-eligi- 11. Prioritize the development of a replace- ble infants).33 Thus, at least in the short term, ment system for MEDS. An independent tech- the Gateway will be one of the few avenues to nical assessment of the system found that it immediate health services for children while would take “at least six years” to implement a their families supply the appropriate paperwork. replacement system. It is likely that the system will reach a crisis point even earlier.32 While the automatic file clearance system developed for the CHDP Gateway works adequately, the reality of Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 25 Conclusion The CHDP Gateway represents an unprecedent- ed experiment in using automated matching against a complex database, in using temporary Medi-Cal coverage to pay for health assessment services and other immediate medical needs, and in using health delivery sites and well-child care as an entry point into continuous coverage. It has succeeded in pre-enrolling large numbers of children and giving them temporary Medi-Cal coverage. Further, its screening and pre-enroll- ment technology successfully interfaces with MEDS and offers a solid foundation for expand- ing automatic enrollment into coverage for more children. However, the Gateway has been far less successful in achieving continuous coverage. Most of its challenges arise from complex issues that predate the Gateway itself: the problems with MEDS, the complexity of the joint application, and a patchy eligibility system in which some siblings within the same family may be eligible for cover- age when others are not. The Gateway’s automation is a powerful tool that should be refined and improved as the program moves forward. It points to the value of short- term improvements, including technological and policy fixes to improve follow-up, and better training and coordination. On a broader scale, the research findings suggest that the state should analyze the role of the Gateway in expanding health insurance coverage for children, and maxi- mize its effectiveness as part of a comprehensive strategy to streamline and integrate enrollment in public programs. 26 | CALIFORNIA HEALTHCARE FOUNDATION Appendix A: CHDP Gateway Data Elements* and Analytical Findings Data Element Figure Data Detail Considerations and Implications Pre-enrollments and visits to CHDP providers Health assessment 785,480 Figure includes: visits/CHDP • Successful pre-enrollments, Gateway encounters including multiple visits. • Denials. Health assessment 712,755 • Number of health assessment Includes children who pre-enroll visits resulting in visits during which a child is more than once; not an undupli- Gateway pre- pre-enrolled into temporary cated count of children. enrollment Medi-Cal (“successful pre- enrollments”). • Excludes denials. Successful pre- 8W: 527,230 Figures exclude: denials. See Table 1 in Appendix B for aid enrollments into 8X: 78,531 code definitions. temporary Medi-Cal 8U: 63,706 by aid code 8Y: 43,167 8V: 121 Number of children 613,575 Unduplicated count of children Includes children in aid codes 8U pre-enrolling in pre-enrolling. and 8V; these children are not temporary Medi-Cal Figure excludes: required to return a joint application • Denials. for continuous coverage. • Multiple visits by same child. Children pre-enrolling 77,834 Subset of 613,575 figure. • 2 visits: 60,795 more than once • 3 visits: 13,323 • 4 visits: 3,147 • 5 visits: 547 • > 5 visits: 22 Percentage of children 12.6% pre-enrolling more than once Joint applications for Medi-Cal/Healthy Families Requests for joint 551,250 Family checks “yes” to state- Counts instances, not individuals. applications at time ment “I want to apply for con- Includes 8W and 8X pre-enroll- of CHDP tinous coverage through Medi- ments—8U pre-enrollees can pre-enrollment Cal or Healthy Families.” request an application but it is not Excludes denials. sent out because they will be automatically enrolled as deemed eligibles. Percentage of 91.0% Requests for joint applications pre-enrollments from 8W and 8X pre-enrollees in which applications (551,250), divided by total number were requested of 8W and 8X pre-enrollments (605,761). Individual children for 109,287 Number of pre-enrolled children Includes applications from pre- whom applications in aid categories 8W and 8X for enrollees who requested join are returned and whom applications were returned applications be sent to them, as temporary eligibility to the Single Point of Entry or well as from pre-enrollees who (8W,8X) was any other point of intake within did not. extended the period of CHDP Gateway eligibility. * Data for the period October 1, 2005–September 30, 2006. Source: California Department of Health Services Information and Technology Support Division (ITSD). Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 27 Data Element Figure Data Detail Considerations and Implications Joint applications for Medi-Cal/Healthy Families (cont.) Percentage of 8W 18.0% Number of pre-enrolled children and 8X pre- in aid categories 8W and 8X for enrollments in which whom applications were temporary Medi-Cal returned to the Single Point of coverage was Entry or any other point of intake extended within the period of CHDP Gateway eligibility (109,287), divided by total 8W and 8X pre-enrollments (605,761). Individual children 155, 595 Number of pre-enrolled children Includes applications from pre- (in aid codes 8W, 8X) in aid categories 8W and 8X for enrollees who requested applica- for whom application whom applications were tions be sent to them, as well as was returned within returned to the Single Point of from pre-enrollees who did not. 90 days of Gateway Entry or any other point of intake pre-enrollment within 90 days of the CHDP Gateway application date. Eligibility determination and continuous coverage Gateway children 55,743 Children pre-enrolled through the Includes deemed-eligible infants enrolled into Gateway who were determined (aid code 8U) who convert to con- continuous, full-scope eligible for continuous, full-scope tinuous full-scope aid code. Medi-Cal Medi-Cal. Gateway children 11,796 Children pre-enrolled through the MRMIB reports 17,829 Gateway enrolled in continuous Gateway who were determined children enrolled in Healthy Healthy Families eligible for Healthy Families. Families during the period 10/1/05–9/30/06. Gateway children 7,988 Children pre-enrolled through the enrolled in continuous, Gateway who were determined limited-scope eligible for continuous, limited- Medi-Cal scope Medi-Cal. Percentage of 11.0% Children enrolling into full-scope children who gain Medi-Cal or Healthy Families continuous coverage (67,539), divided by total number in full-scope Medi-Cal of children pre-enrolled or Healthy Families (613,575). via the Gateway Percentage of 12.3% Children enrolling into Medi-Cal children who gain (including limited-scope) or continuous coverage Healthy Families (75,527), divid- in Medi-Cal (including ed by total number of children limited-scope) or pre-enrolled (613,575). Healthy Families via the Gateway * Data for the period October 1, 2005–September 30, 2006. Source: California Department of Health Services Information and Technology Support Division (ITSD). 28 | CALIFORNIA HEALTHCARE FOUNDATION Appendix B: Elements of the Gateway Process Intake and Electronic Interface CHDP Gateway, among them eligibility verifica- A Gateway visit begins when an uninsured, low- tion, Share of Cost clearance, and submission of income child not currently enrolled in full-scope, pharmacy claims.36 no-cost Medi-Cal or Healthy Families presents After logging into the system, the staff member for an exam at a CHDP provider’s office. Staff first encounters a verification screen, on which review a state-produced document, the Gateway he/she enters the information that the parent pro- Pre-Visit Flyer (PUB 139), with the parent.34 vided on the CDHS 4073, including the response They describe services for which children are eli- to the question about receiving a paper applica- gible with a temporary Benefits Identification tion in the mail to apply for continuous coverage. Card (BIC), the temporary nature of coverage, An online screen immediately checks the income the potential impact on immigration status against CHDP standards. If the family income is (none), and what families need to do to apply for too high, the staff member will receive a message continuous coverage. to that effect; otherwise, he/she will be instructed To begin the process, the parent, guardian, or an to proceed to the Application screen. emancipated minor completes and signs a “pre- The application screen asks whether the patient enrollment” form, the CHDS 4073.35 This form has a Benefits Identification Card (BIC), indicat- asks for general demographic information about ing that the client is known to MEDS, and then the child and his or her family, the number of for the name (last, first, middle initial), date of people in the family, and family income before birth, gender, address, and Social Security taxes. At this time, the parent chooses whether to Number. This last is optional and, in site visits apply for continuous coverage through Medi-Cal conducted for this report, was not asked. The or Healthy Families. A check-box allows the par- staff member then continues by filling in the ent to request a paper application for Medi-Cal mother’s name and, for patients under age one, and Healthy Families (MC 321). (Three addi- whether the child lived with the mother in the tional information requests are included on the month of his/her birth, and, if so, the mother’s pre-enrollment screening form for a newborn, as date of birth and BIC number, Medi-Cal card described below.) Even with the program’s number, or Social Security Number. automation, providers are required to keep a copy of the completed CHDS 4073 on file to The application screen asks whether that day’s verify authenticity and for audit purposes. (Prior CHDP visit is within the CHDP periodicity to the Gateway, providers were required to send schedule. The provider may know the date of the the 4073 to EDS along with the PM 160 as part child’s last assessment, either from existing med- of the billing process; this paper transaction is no ical records or parent report. (If the provider does longer necessary.) not know, he/she will discover if the child is eligi- ble for another health-assessment screening only The rest of the process is completed by a staff when they send the Gateway transaction and member, using the Internet (Medi-Cal Web site) receive a message stating that the child is not eli- or a Point of Service (POS) device. The Point of gible.)37 If the provider knows that the CHDP Service device looks like a credit card terminal visit is not within periodicity, the provider can with a small keyboard attached. The Internet identify the screening visit as a Medically interface is hosted on the Medi-Cal Web site. Necessary Interperiodic Health Assessment Both systems can be used for services beyond the (MNIHA), which permits assessments outside the regular periodicity schedule. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 29 Finally, the provider enters the name of the Increased availability of One-e-App should help patient’s parent or legal guardian, his/her phone families submit a complete and correct joint number and primary spoken and written lan- application. One-e-App can also serve as an inte- guages, and certifies that the CHDS 4073 has grated system with which multiple programs can been signed. interact, addressing concerns that programs such as Gateway are “one-off” solutions that work Providers have an opportunity to review and edit only with single, specific programs. their entries before submitting them, either on the application screen or by moving to an appli- cation summary screen, which displays all the Pre-Enrollment and Temporary responses. From that screen, providers can go Coverage “Back to Application” to edit an entry; print the There are several possible outcomes for a child application summary; or submit the completed who is screened by the Gateway for CHDP serv- Gateway transaction. ices and temporary Medi-Cal. The basic outcome Clicking the “Submit Application” button at categories include: the bottom of the application returns a prompt 1. There is no record of the child in MEDS. In this asking whether the provider has verified the case, they are eligible for “pre-enrollment,” data and printed a copy of the Application temporary full-scope Medi-Cal for up to 60 Summary. A “No” response allows the provider days and a CHDP exam. back into the application screen; a “Yes” submits the application. 2.The child is known to MEDS, and is either: (a) already enrolled in Medi-Cal or Healthy Once submitted, the CHDP Gateway transac- Families; (b) currently pre-enrolled through the tion is sent to MEDS, which checks the child’s CHDP Gateway or another accelerated program; name, birth date, gender, and address against its or (c) a full-scope, no-cost Medi-Cal beneficiary. records to determine the child’s eligibility for pre- The system will tell the provider that the child enrollment. MEDS typically returns a response has existing Medi-Cal coverage. If the child has within seconds. an assigned provider who is not the CHDP provider, the child will be referred to the assigned provider for care. Gateway Connection to One-e-App 3. The child is already enrolled in Medi-Cal with One-e-App, a Web-based system for connecting an aid code linked to undocumented immigration families with a range of publicly funded health status. The child is eligible for a state-funded and social service programs, is used in five coun- CHDP exam, depending on periodicity, but ties to screen and electronically route applications not for pre-enrollment and temporary full- for programs such as Medi-Cal, Healthy scope Medi-Cal coverage. Families, Healthy Kids, and county indigent care. The Center to Promote HealthCare Access, Inc., In all cases, the provider prints out the message recently added the Gateway to the list of pro- returned by the system (the “CHDP Gateway grams to which data can be routed. That inter- Pre-Enrollment Response”) and gives it to the face was launched in Los Angeles and San familiy. The response does not reference the Joaquin counties in February, 2007 and March, child’s specific aid category (this is available to 2007, respectively. It is expected that other the provider if they print an Eligibility Inquiry counties with One-e-App will include the Response; see Table 1 for a list of CHDP CHDP interface in their suite of programs. Gateway eligibility aid codes) or immigration sta- tus, but includes the patient’s name, date of 30 | CALIFORNIA HEALTHCARE FOUNDATION birth, gender, BIC number, BIC issue date (and Cal/Healthy Families application. As of January end date, if applicable), the provider’s number, 2006, provider’s offices are required to maintain and a brief message explaining the outcome and copies of the joint Medi-Cal/Healthy Families next steps for the provider and patient. If the applications to distribute to parents at the time parent did not request an application earlier in of a Gateway screening.40 the process, the message provides instruction on how to obtain one. The provider prints the Completing the Joint Application Response for the family and keeps a copy.38 and Application Follow-Up In cases in which a child is eligible for pre-enroll- A family that has elected to apply for continuous ment, the Gateway system will enroll the child in Medi-Cal or Healthy Families coverage must temporary full-scope Medi-Cal for the remainder complete and send in the joint application before of the month of service and the month follow- their child’s temporary coverage expires to main- ing. If the child does not already have a BIC, tain coverage past the expiration date. If a family the Pre-Enrollment Response operates as an has not returned an application by 15 days before immediate-need document—when signed by the the end of the temporary coverage period, parent, it can be used that day to receive Medi- CDHS sends a reminder notice. Cal covered services, including physician and dental care, prescriptions, hospital, lab, and Families may apply through other means dur- other services. The family leaves the provider’s ing the coverage period, including working office with this document and with a flyer directly with a county eligibility worker or a explaining how to apply for continuous certified application assistor at the CHDP coverage.39 The Gateway system initiates a trans- provider’s office or elsewhere, or through action request for a Medi-Cal Benefits another mechanism. Identification Card (BIC), which is produced Local CHDP programs have access to Business and mailed the next working day. The family Objects, a software reporting system that allows should receive the BIC in two to five days. The state and county staff to view CHDP Gateway BIC replaces the immediate-need document and data online and to download detailed reports serves as the child’s Medi-Cal card until the end about Gateway applications. The data in Business of the temporary coverage period. Objects is compiled by the California In a separate mailing, families who apply for Department of Health Services (CHDS) Fiscal continuous coverage receive a joint Medi- Intermediary from the CHDP Confidential Table 1: Medi-Cal Aid Codes for the CHDP Gateway 41 8U Deemed-eligible newborns from day of birth through first year of life; full-scope Medi-Cal with no share of cost (SOC) required, provided they continue to meet all other eligibility requirements. Federal financial participation available. 8V Deemed-eligible newborns from day of birth through first year of life; full-scope Medi-Cal with a share of cost required,. Federal financial participation available. 8W Probable no-cost Medi-Cal–eligible children. Provides temporary, full-scope Medi-Cal benefits with no SOC. Federal financial participation available. 8X Probable Healthy Families–eligible children. Provides temporary, full-scope Medi-Cal benefits with no SOC. Federal financial participation available. 8Y Undocumented immigrant children known to MEDS. This aid code category is not eligible for federal financial participation, but state-only funding. Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 31 Screening/Billing Report forms (PM 160s), the I The child is denied coverage because he/she is CHDP Provider Master File, and the Gateway not eligible. At this point, temporary Medi-Cal transactions file.42 Local CHDP offices can use coverage is terminated; depending on eligibility Business Objects reports or PM 160 forms and local coverage options, the family may be returned to the county to conduct follow-up referred to other coverage. with families and provide application assistance. I The child’s application is missing information However, there is no state requirement that necessary to complete an eligibility determina- CHDP staff use Business Objects or any other tion. A letter detailing the missing information means to track the progress of joint applications is mailed to the family. If the family does not or follow up with pre-enrolled children. return the documents in time, the application is denied. Eligibility Determination When a family mails in a completed application Newborn Enrollment as with all required documentation, the Single Point “Deemed Eligible” of Entry (SPE) routes the application to the Since 2004, infants under one year of age are appropriate county welfare office or to the “deemed eligible” if they were born to mothers Healthy Families administrative vendor who had Medi-Cal coverage at the time of deliv- (Maximus). The SPE also sends a transaction to ery. Parents of these infants must fill in three MEDS, which removes the end date for tempo- additional fields on the CHDS 4073 form, under rary Medi-Cal coverage. This process extends the the section “For Infants Under One Year of Age”: child’s temporary coverage until a final eligibility I Did the infant live with the mother in the determination is made. (Healthy Families has 20 month of birth? days to make this determination, while Medi-Cal has 40–60 days to make this determination.) I Mother’s date of birth. CDHS mails the family a letter informing them I Mother’s Benefits Identification Card (BIC) ID that their application has been received and is number or Social Security Number. being processed. Parents of infants who are deemed eligible during Notably, there is nothing on the paper applica- pre-enrollment screening at the CHDP provider’s tion that marks it as an application from a child office do not need to complete the joint applica- who has been through the CHDP Gateway. For tion. The state provides a CHDP Parent Flyer for staff at SPE, the joint application is like any Newborn Enrollment (PUB 186), which explains other, and the file clearance process proceeds the difference between deemed-eligible enroll- exactly as it would for a child who had not ment and temporary coverage. Parents should get encountered the Gateway. this notice at their CHDP visit.43 Possible final outcomes of the eligibility determi- Infants who cannot be linked to a Medi-Cal nation process for Medi-Cal or Healthy Families mother—for example, when a mother cannot include: supply her BIC number at her CHDP visit— I The child is enrolled in full-scope Medi-Cal or are not allowed to be deemed eligible under the Healthy Families. CHDP process, and instead go through the HDP Gateway process as described above, receiv- I The child is enrolled in limited scope or emer- ing temporary full-scope coverage, which will gency Medi-Cal. end unless they file an application for continuous coverage. 32 | CALIFORNIA HEALTHCARE FOUNDATION Endnotes 1. California Department of Health Services. CHDP 17. California Department of Health Services. Data from Gateway Internet Step-by-Step User Guide, June, 2004. November 2004–October 2005, on file with California (http://files.medi-cal.ca.gov/pubsdoco/publications/ HealthCare Foundation. Masters-Other/CHDP/userguide/gateway_guide.pdf ). 18. California Department of Health Services. “EDS 2. Legislative Analyst’s Office. “Child Health and Disability Processed Claims, CY 2004.” Source: MCSS Pivot Table Prevention Program: Department Not Enforcing F35 Summary Pivot Table 2004 to 2006. May 5, 2006. Treatment Requirement.” Analysis of the 1997–98 On file with the California HealthCare Foundation. Budget Bill C-64 (www.lao.ca.gov/analysis_1997/ 19. California Department of Health Services. Comments health_ss_anal97.pdf ). on the CHDP Gateway DRAFT report, November 6, 3. 42 U.S.C. § 1397 et seq. 2006, 21. On file with the California HealthCare 4. Legislative Analyst’s Office. Obstructed Entry: CHDP Foundation. Fails as Gateway To Affordable Health Care. January 30, 20. California Department of Health Services. Comments 2001 (www.lao.ca.gov/2001/chdp/013001_chdp.html). on the CHDP Gateway DRAFT report, November 6, 5. Ibid. 2006, 22. On file with the California HealthCare Foundation. 6. Ibid. 21. Eclipse Solutions, Inc. Medi-Cal Eligibility Data System 7. Ta, Van M., M.P.H., and Lucien Wulsin, Jr., J.D. (MEDS) Assessment Project, June 2004. More specifical- A Summary of Health Care Financing for Low-Income ly, the duplicates are part of the Statewide Client Index Individuals in California, 1998 to 2005. Insure the (SCI), “a combination of applications and telecommuni- Uninsured Project (ITUP), February 3, 2005 cation infrastructure that was developed in 1994 to allow (www.itup.org/pdfs/OverviewofCA98-05.pdf ). access to beneficiary information for file clearance pur- 8. Legislative Analyst’s Office. 2006–07 Analysis. February poses. Several state agencies and departments utilize this 23, 2006 (www.lao.ca.gov/analysis_2006/health_ss/ system to establish identity information... Originally healthss_anl06.pdf). developed for use by DHS and MEDS, it usage has grown far beyond its original scope and now services a 9. 2006 Cal. Stat. 332. great number of different applications and programs.” 10. 2006 Cal. Stat. 328. 22. Ibid, page 3. 11. California’s Medi-Cal Eligibility Data System (MEDS). 23. California Department of Health Services, “Your MEDS is a database of Medicaid recipients, managed Child Now Has FreeTemporary Medi-Cal Health under the Department of Health Services. Coverage” (Gateway Post-Visit Flyer) June 5, 2003 12. California Managed Risk Medical Insurance Board. (www.dhs.ca.gov/ pcfh/cms/chdp/pdf/postvisitenglish. Healthy Families Historical Reports. (www.mrmib.ca.gov/ pdf). MRMIB/HFPReportsHis.shtml). 24. Horner, Dawn. California’s Express Enrollment Program: 13. CDHS Information andTechnology Support Division. Lessons from the Medi-Cal/School Lunch Pilot Program – Personal communication with Jina Wang, January 25, And Suggested Next Steps in Making Enrollment Gateways 2007. The CDHS 4073 asks two questions about lan- Efficient and Effective. The Children’s Partnership, July, guage: “What language do you speak at home?” and 2006 (www.expresslaneinfo.org/ AM/ Template.cfm? “What language do you read best?” Staff at CDHS Section=Reports2&TEMPLATE=/CM/ContentDisplay. ITSD reported that the responses for language are cfm&CONTENTID=9815). “primarily written language,” with spoken language 25. California Health Interview Survey, 2005. Eligibility of counted “if written language is invalid.”. Uninsured under 65 for Medi-Cal/Healthy Families, 14. Eclipse Solutions, Inc. Medi-Cal Eligibility Data System Data accessed February 12, 2007. www.chis.ucla.edu. (MEDS) Assessment Project, June 2004. 26.Overton, Lisa. “Simplify, Automate andFollow the 15. Managed Risk Medical Insurance Board. “CHDP Leader: Lessons on Expanding HealthCoverage for Gateway Initiated Applications Statistics, 03-Oct-06” Children.” California HealthCareFoundation, November (for the period October 2005 through September 2006). 2006 (www.chcf.org/topics/medi-cal/index.cfm? (www.mrmib.ca.gov/MRMIB/HFP/Sep_06/ itemID=127290). HFPRpt31.pdf.) 16. Managed Risk Medical Insurance Board. “CHDP Gateway Initiated Applications Statistics, 03-Oct-06” (for the period October 2005 through September 2006). (www.mrmib.ca.gov/MRMIB/ HFP/Sep_06/ HFPRpt31.pdf). Connecting Kids to Health Coverage: Evaluating the Child Health and Disability Prevention Gateway Program | 33 27. California Department of Health Services. Comments 37. California Department of Health Services. Children’s on the CHDP Gateway DRAFT report, November 6, Medical Services, Child Health and Disability 2006, 31. On file at the California HealthCare Prevention Program, Provider Concerns (n.d.). Foundation. According to CDHS, “[t]he greatest bar to (www.dhs.ca.gov/pcfh/cms/chdp/gateway/provider.htm). getting complete data on Gateway children is the fact 38. Most CHDP providers fill out a separate form, the PM that the Social Security Number (SSN) is not request- 160, for payment and reporting of health assessment ed/provided. As long as there are CIN numbers assigned services. They submit one copy to the billing administra- when children do not have SSNs, there is the possibility tive vendor for payment and another to their local of overcounting unduplicated beneficiaries/users.” CHDP program. Certain clinics, including Federally 28. California Department of Health Services. All County Qualified Health Centers, Rural Health Centers, and Welfare Directors Letter No. 03-33. “Implementation of Medi-Cal Managed Care providers, are paid differently Child Health and Disability Prevention Program but still are required to submit Information-Only PM Gateway.” June 18, 2003. (www.dhs.ca.gov/mcs/mcpd/ 160 forms to the county. Traditionally, these forms have meb/acls/PDFs/ACWDLs/2003ACLs/30s/c03-33.pdf). been used by local CHDP programs to track children’s 29. California Department of Health Services. Children’s health status and provide follow-up assistance, particu- Medical Servicves, CHDP Provider Information Notice larly to children referred for additional services. No. 04-08, March 30, 2004. Before the Gateway was 39. California Department of Health Services. modified to accept information to deem newborns eligi- (www.dhs.ca.gov/pcfh/cms/chdp/pdf/ ble, a CHDP Provider Information Notice recommend- postvisitenglish.pdf ). ed that in the interim providers complete a Newborn 40. California Department of Health Services. CHDP Referral Form (MC 330) and forward it to the county. Provider Information Notice No: 06-01. January 11, (www.dhs.ca.gov/pcfh/cms/onlinearchive/pdf/chdp/provi 2006 (www.dhs.ca.gov/pcfh/cms/onlinearchive/ derinformationnotices/2004/chdppin0408.pdf). pdf/chdp/programletters/2006/chdppl0601.pdf). 30. California Department of Health Services. Comments 41. California Department of Health Services. All County on the CHDP Gateway DRAFT report, November 6, Welfare Directors Letter No. 03-33, June 18, 2003, 2006, 2. On file with the California HealthCare adapted. (www.dhs.ca.gov/mcs/mcpd/meb/acls/ Foundation. PDFs/ACWDLs/2003ACLs/30s/c03-33.pdf). 31. California Department of Health Services. Comments 42. California Department of Health Services. Children’s on the CHDP Gateway DRAFT report, November 6, Medical Services, CHDP Program Data Reporting 2006, 33. On file with California HealthCare System with Business Objects. (www.dhs.ca.gov/pcfh/ Foundation. cms/chdp/chdpbo.htm). 32. Eclipse Solutions, Inc. Medi-Cal Eligibility Data System 43. California Department of Health Services. (MEDS) Assessment Project. June, 2004. (www.dhs.ca.gov/pcfh/cms/chdp/pdf/parentinfoeng.pdf). 33. California Department of Health Services. All County Welfare Directors Letter No. 07-12. “Implementation of the Federal Deficit Reduction Act of 2005 Requirement to Provide Evidence of Citizenship/U.S. National Status as a Condition of Medi-Cal Eligibility.” June 4, 2007. (www.dhs.ca.gov/mcs/mcpd/MEB/ACLs/ PDFs/ ACWDLs/2007ACLs/10thru19/c07-12.pdf). 34. California Department of Health Services. (www.dhs.ca.gov/pcfh/cms/chdp/pdf/ previsitenglish.pdf). 35. California Department of Health Services. (www.dhs.ca.gov/publications/forms/ pdf/dhs4073.pdf). 36.California Department of Health Services. Point of Service (POS) Device User Guides. (http://files.medi- cal.ca.gov/pubsdoco/ugframe.asp?hURL=/Pubsdoco/ pos_home.asp). 34 | CALIFORNIA HEALTHCARE FOUNDATION