Medicaid Eligibility, Enrollment, and Renewal Processes and Systems Study CASE STUDY SUMMARY REPORT – IDAHO Prepared for: Medicaid and CHIP Payment and Access Commission (MACPAC) Prepared by: State Health Access Data Assistance Center (SHADAC) Division of Health Policy and Management University of Minnesota, School of Public Health October 19, 2018 i TABLE OF CONTENTS ACKNOWLEDGEMENTS ..................................................................................................................... II INTRODUCTION .................................................................................................................................1 STRUCTURE OF MAGI MEDICAID ENROLLMENT AND RENEWAL ...........................................................2 Application options and eligibility systems........................................................................................... 2 Electronic verification for MAGI Medicaid beneficiaries ...................................................................... 5 Auto-enrollment and renewal .............................................................................................................. 7 Integration of MAGI Medicaid eligibility determination with other health or human services programs ............................................................................................................................................... 8 MEDICAID PROGRAM AND BENEFICIARY EXPERIENCES .......................................................................9 High-touch customer service led to efficient application process for health and non-health services.................................................................................................................................................. 9 Robust, horizontally integrated rules engine was critical in supporting high-touch customer service ................................................................................................................................................. 10 Electronic data interfaces facilitated high rates of real-time eligibility determinations, auto-renewal, and reduced churn ...................................................................................................... 11 Combined online application served as a single portal to health coverage, enhanced beneficiary access, and reduced burden ............................................................................................................... 11 LOOKING FORWARD ........................................................................................................................12 REFERENCES ....................................................................................................................................13 APPENDIX: PRE-TELEHONE DISCUSSION DATA COLLECTION FORM ................................................. A-1 State Health Access Data Assistance Center ii ACKNOWLEDGEMENTS This project was conducted by the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota, School of Public Health, Division of Health Policy and Management. It was funded through a contract with the Medicaid and CHIP Payment and Access Commission (MACPAC). The findings, statements, and views expressed are those of the authors and do not necessarily represent those of MACPAC. Authors of six state summary reports and a synthesis report were Emily Zylla, Caroline Au-Yeung, Elizabeth Lukanen, and Christina Worrall. Authors would like to acknowledge the many contributions made to this effort by MACPAC staff members Martha Heberlein and Kate Kirchgraber. We would also like to thank the 48 key informants in Arizona, Colorado, Florida, Idaho, New York, and North Carolina for sharing their time and insights about their experiences implementing streamlined Medicaid eligibility, enrollment, and renewal practices in their respective states. Finally, we would like to recognize Jeannine Ouellette and Andrea Stewart for their work reviewing and proofing the reports, and Lindsey Lanigan and Ann Conmy for their work on the layout, exhibits, and production of the reports. State Health Access Data Assistance Center 1 INTRODUCTION Over the last decade, simplifying and streamlining state Medicaid enrollment and renewal processes and systems have been a priority for state agencies. These changes were accelerated with the passage of the Patient Protection and Affordable Care Act (ACA) in 2010. The ACA called for enhancements to Medicaid, including the implementation of revised eligibility rules, a single streamlined application, and use of technology to verify and exchange data in support of near real-time eligibility determinations. 1 Additionally, the Centers for Medicare & Medicaid Services (CMS) and other federal agencies provided states with guidance and incentives to modernize and integrate eligibility systems in order to efficiently enroll Medicaid-eligible individuals. As the legislative branch agency charged with advising Congress on Medicaid and the Children’s Health Insurance Program (CHIP), the Medicaid and CHIP Payment and Access Commission (MACPAC) sought to better understand the post-ACA status of state systems and processes used to support Medicaid program eligibility, enrollment, and renewal. To do so, MACPAC contracted with the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota, School of Public Health to conduct an assessment in selected states of current Medicaid eligibility, enrollment, and renewal practices, and the extent to which they are achieving desired goals (such as program efficiency and simplified beneficiary experience). A case study approach was used to collect data regarding the state of practices associated with enrolling the Medicaid population for which income eligibility is determined based on Modified Adjusted Gross Income (MAGI). Specifically, we assessed auto-enrollment and auto-renewal practices, the use of electronic data sources for verification, and the degree of integration with non-MAGI Medicaid populations and other public benefit programs. Case studies did not focus on other aspects of Medicaid enrollment, namely outreach and consumer assistance, community partnerships, enrollment and credentialing of providers, and call center technology. The study focused on six states (Arizona, Colorado, Florida, Idaho, New York, and North Carolina) where documentation showed steps toward implementing streamlined, automated or integrated approaches to Medicaid enrollment and renewal. States were selected based on a literature scan as well as discussions with MACPAC and external experts and represented diversity across a range of characteristics including Medicaid program size, exchange type, adoption of the ACA Medicaid expansion, current enrollment and renewal practices, geography, and political climate. This case study summary report includes findings from Idaho based on: telephone interviews with seven key informants conducted in May and June of 2018; a review of publicly available and state-provided documents (e.g., verification plans submitted to CMS); and data collected in advance of telephone discussions on the organization of the state’s Medicaid program, eligibility system, and other information technology resources to support MAGI Medicaid eligibility determination. (See the Appendix for a copy of the data collection form used to gather information in advance of telephone interviews with state agencies.) Key informants (also referred to as respondents) in Idaho represented state Medicaid eligibility and Medicaid program administration staff, the state-based exchange, and two advocacy organizations. The case study begins with an overview of Medicaid in Idaho and a high-level description of how individuals apply and how their eligibility is determined for MAGI Medicaid populations. Included in this 1 According to CMS guidance, real time refers to no delay between submission of a complete and verifiable application and the response to the applicant. (CMS, n.d.) State Health Access Data Assistance Center 2 overview section are case study findings related to the approaches Idaho is taking to streamline enrollment and renewal for MAGI Medicaid populations. Next, we present key themes, as identified by key informants, related to Medicaid program and beneficiary experiences, including successes and challenges of Idaho’s approaches. Lastly, we summarize ongoing issues and future plans in the study state to further simplify and streamline enrollment. STRUCTURE OF MAGI MEDICAID ENROLLMENT AND RENEWAL Idaho’s Medicaid and separate State Children's Health Insurance Program (CHIP) reside in the Idaho Department of Health and Welfare. Within that department, the Division of Welfare assesses eligibility for Medicaid, CHIP, exchange plans, and other non-health programs, called Self Reliance Programs (e.g., the Idaho Food Stamp Program or Supplemental Nutritional Assistance Program [SNAP], Temporary Assistance for Families [TANF], and the Idaho Child Care Program). A separate division, the Division of Medicaid, supports post-eligibility administration of the Medicaid program, such as provider and claims management. 2 Under the ACA, Idaho established a state-based health insurance exchange called Your Health Idaho, a quasi-governmental organization designed to support the purchase of exchange plans. Table 1 provides an overview of Medicaid eligibility and Advanced Premium Tax Credit (APTC) thresholds in the state. 3 Despite not choosing to expand Medicaid, Idaho has seen a 13 percent growth in Medicaid enrollment between the July through September 2013 period and April 2018. As of April 2018, total Medicaid and CHIP enrollment was 268,000 individuals, or 16 percent of the state’s population (CMS 2018, U.S. Census 2017). Table 1. Idaho MAGI Medicaid Eligibility and Advanced Premium Tax Credit (APTC) Thresholds, by Coverage Group, 2016 Coverage Group 100% FPL 200% FPL 300% FPL 400% FPL Pregnant Women 138% (Medicaid) > 138%–400% (APTC) Children (Age 0–18) 190% (Medicaid/CHIP) > 190%–400% (APTC) 31% No coverage Individual Parents and Caretakers 100%–400% (APTC) (Med.) available No coverage Single Adults available 100%–400% (APTC) Sources: Brooks et al. 2018; DHW 2016; Data collection and verification under the 2018 Assessment of Medicaid Eligibility, Enrollment and Renewal Processes and Systems project, Medicaid and CHIP Payment and Access Commission (MACPAC) contract number MACP18417T1. Notes: Eligibility levels are reported as percentage of the Federal Poverty Level (FPL). Percentages include the five percentage point disregard established under the ACA, which can be applied to eligibility determination for MAGI Medicaid individuals. Acronyms are as follows: MAGI – Modified Adjusted Gross Income, CHIP – State Children's Health Insurance Program. Application options and eligibility systems Consistent with federal law, applications for Medicaid in Idaho can be submitted through multiple modes: in person, mail, telephone, and online. Respondents indicated that applications are primarily submitted in person. In Idaho, only 20 percent of applications are submitted online (compared to a national average of 50 percent), 30 percent are submitted via phone, and 50 percent are submitted another way (including in person) (Brooks et al. 2018). Respondents described the state approach to the application process as prioritizing in-person or phone-based application support (discussed in more 2 The Division of Medicaid performs eligibility determination on select non-MAGI groups that need level of care determinations such as Katie Beckett program and processes renewals for all non-MAGI beneficiaries. 3 APTC is a mechanism for consumers to receive financial assistance (i.e., lower monthly premiums) to purchase health insurance coverage through an exchange. State Health Access Data Assistance Center 3 detail below). As one respondent said, “One of the things that sort of sets Idaho apart, and I think that it is amazing, is that we really don't rely on a lot of online applications for our applicants…we really encourage people to pick up the phone and call us to do an application or come into an office and talk to us face-to-face. Because then we can get the full picture and hopefully do an entire eligibility determination right there, either on the phone or in person with the customer.” Both the paper application and the online application, idalink (the state’s only online application for health insurance programs), serve as a single, combined application for all health care programs, including MAGI and non-MAGI Medicaid, CHIP, exchange plans, Medical Savings Program, and other waiver programs. 4 Described as a “smart application,” idalink tailors the amount of information required from an applicant based on individual circumstances and responses to questions. Within idalink, once the individual sets up an account, they can make changes to their family situation, upload documents, and see notices. Individuals interested in receiving non-health benefits (such as SNAP or TANF) must contact the Department of Welfare directly to apply for services. Respondents cited this as the primary reason for promoting in-person and phone-based applications. One respondent explained, “That's why we typically say, if you don't know exactly what you want or what you might qualify for and you are just looking for any help or any assistance that we're able to give you, it's always better to just call us. You can apply over the phone for all of our benefit programs and that self-reliance specialist, that field staff person that answers the phone, is a generalist in that they understand all of our programs and they can pretty seamlessly and quickly determine what you might be eligible for and then process eligibility for all of those programs.” Notably, once a beneficiary is enrolled in a non-health program, they can set up an idalink account and view or manage certain aspects of their account, even though they are not able to apply through idalink (e.g., a SNAP beneficiary can view account information and complete re-evaluation online) (Shaw et al. 2015). The customer service-focused application process is supported by a state-wide eligibility workforce trained to serve all health and social service programs (respondents called this a “universal workforce”). In addition, Idaho has a statewide phone system that routes calls to staff based on their availability. Respondents noted that this feature allows high call volumes to be efficiently managed at a specific regional service center, as call routing patterns can be adjusted to available staff located anywhere in the state. All application information, first keyed into idalink from paper forms by an eligibility worker, is submitted to Idaho Benefits Eligibility System (IBES), the state’s eligibility system, which resides in the Department of Welfare. IBES was implemented in 2009 to serve as a single, state-wide, web-based integrated eligibility system for Medicaid and other human service programs such as SNAP and cash assistance, replacing a mainframe system in existence since 1985. With the passage of the ACA, IBES was enhanced to determine eligibility for all health programs, including health insurance coverage available through the exchange. In addition, it houses business rules for SNAP, TANF, and child care, while supporting connections that enable access to electronic data sources (described in the next section) with a variety of partner agencies, such as Women, Infants, and Children (WIC). 4 If an individual applies for health coverage through Your Health Idaho and indicates that they would like financial assistance, the applicant is automatically transferred to the idalink online application. State Health Access Data Assistance Center 4 The decision to have the Department of Welfare process eligibility for both Medicaid and exchange plans was based on the timing of the development of Your Health Idaho and direction from CMS encouraging the state to leverage its existing robust IBES system. Legislation establishing Your Health Idaho became law in late March 2013 (see Exhibit 1), leaving limited time to design and implement the new health insurance exchange before the first open enrollment period in the fall of 2013. For this reason, the state opted to use healthcare.gov (the federal exchange) during the first open enrollment period. This gave the state extra time to fully develop and test Your Health Idaho’s information technology (IT) platform, which launched in advance of the second open enrollment period in the fall of 2014. Respondents felt that that the timing of the launch allowed the state to learn from the experiences of first-generation state-based exchanges. 5 Specifically, many first-generation state-based exchanges sought to make wide-ranging changes (such as non-required functions or updating Medicaid eligibility systems) while also developing eligibility capacity (Leavitt Partners n.d.). Citing the experiences of other states, the state of Idaho made a deliberate decision to leverage the IBES to process eligibility for the exchange and to limit the IT functions of Your Health Idaho. Exhibit 1. Your Health Idaho Across our interviews, respondents spoke very highly of Your Health Idaho and reported being grateful that the state chose to operate a state-based exchange. Respondents highlighted several benefits of the state-based exchange, including state-specific advertising and outreach, a state- specific enrollment assistance program, and the flexibility to extend the open enrollment period. One respondent commented, “I think it was a good decision [to establish a state-based exchange] in the fact that it connected us straight with our Health and Welfare Department. With our own state staff, we're not having to try to explain a farming and ranching job to somebody in New York City…. I know the Your Health Idaho people, I know how to get a hold of someone.…So I'm glad we have a state exchange. It hasn't always been perfect, but they're always working on things, so it's just getting better and better. I think it's been a benefit to us and our patients for sure.” The state has been deliberate in maintaining a limited scope for the exchange, by leveraging the eligibility capacity at the Division of Welfare, and thus avoided creating entities that compete for IT resources. “We’re one of the more efficient exchanges in the country, and I think because we've been very thoughtful in the design…like real-time eligibility….We've been mindful of cost, efficiency, customer experience versus the shiny object that sounds great but is really complex and expensive.” One respondent also reported guidance from CMS encouraged the state to leverage its existing, modernized shared-eligibility system platform to support exchange determinations (the platform had already been updated to incorporate MAGI-rules). One respondent explained, “In discussions with CMS, they said, ‘Hey, you've got a really great eligibility system over in your Medicaid agency. Please use that and add on to that APTC rules. Take the existing rules engine for Medicaid and attach APTC rules to it and figure out how the Medicaid technology and the HIX [state-based exchange] technology are going to interact.’ So that was our mandate, our technology vendor was selected, and we moved forward with that.” Ultimately, Your Health Idaho established an agreement with the Department of Health and Welfare to process eligibility for all applicants seeking an exchange plan; they reimburse the Department for this work through a cost allocation that facilitates the recovery of Department of Health and Welfare costs related to eligibility determination services used by individuals deemed eligible for the exchange as well as related call center activity. 5 Your Health Idaho characterizes itself as a second-generation state-based exchange, because it was implemented in 2014 and not in 2013. State Health Access Data Assistance Center 5 Electronic verification for MAGI Medicaid beneficiaries Idaho’s decision to use the state’s existing eligibility system to support both MAGI Medicaid and exchange eligibility means that the state relies on many electronic eligibility verification processes that pre-dated the ACA, in addition to the Federal Data Services Hub. 6 For example, the state received a waiver from CMS to use an existing connection with the Social Security Administration (SSA) to conduct identity proofing. This existing connection supports more timely eligibility determinations, but it also allows the information to be used to support eligibility determinations for other programs supported by IBES, such as SNAP. Idaho leverages multiple state sources of data to supplement federal income tax information to verify income, including quarterly wage data, which were also described as facilitating more accurate and timely determinations. The state noted that IRS data works well for APTC enrollees who tend to have more stable income, but they described the Work Number (a private, user-paid data source) as being the timeliest source of data on income and more useful for MAGI Medicaid beneficiaries. (See Table 2 for a description of the verification practices and decisions and electronic data sources accessed.) Data are electronically verified using a state-developed verification aggregator called eVerif-I. The eVerif-I tool pulls data from various sources (e.g., Internal Revenue Service [IRS], SSA, the state Department of Labor, etc.) into a single worker dashboard, which is then keyed into IBES. Prior to the development of eVerif-I, workers accessed these data sources through separate portals and on separate screens. Respondents explained the benefit of eVerif-I this way: “It gives staff a single place to log into and then give[s] them access to any of the various interfaces that we have.” They commented that, ideally, all relevant electronic data would integrate automatically into IBES, but eVerif-I supports a more streamlined approach where manual data entry by workers is still needed. 6 The Federal Data Services Hub is an electronic resource developed by the Centers for Medicare & Medicaid Services (CMS) that provides data verification services to state-based exchanges, the federally facilitated exchange, and all Medicaid agencies regardless of expansion adoption. Data sources provided through the hub include those from relevant federal agencies such as the Social Security Administration (SSA), the Department of Homeland Security (DHS), and the Internal Revenue Service (IRS). State Health Access Data Assistance Center 6 Table 2. Idaho Verification Practices for MAGI Medicaid at Application and Renewal Select Eligibility Factor Self-Attestation Financial and Non-Financial Data Sources Notes Federal Agency State Agency Private Income No Social Security Department of Labor, Work Number The state accesses wage data from programs in Administration (SSA), Department of Welfare the Department of Labor (e.g., Unemployment Internal Revenue Service Insurance Benefits, quarterly wage data) and the (IRS) via Federal Data Department of Welfare (e.g., Supplemental Services Hub Nutrition Assistance Program [SNAP], Temporary Assistance for Needy Families [TANF], and Office of Child Support Enforcement). Work Number is used for all applications where wages or work is reported (pre-ACA link). Residency Yes N/A Social Security Number Not allowed SSA Idaho chose to use an existing state connection to SSA through the State Online Query Internet (SOLQ-I) as opposed to Federal Data Services Hub. Citizenship Not allowed SSA Vital Statistics Idaho chose to use an existing state connection to SSA through the State Verification & Exchange System (SVES) as opposed to Federal Data Services Hub. This is a batch query system. The state uses state vital statistics data as a back-up data source to verify citizenship. Household Yes Vital Statistics Used at renewal and post-enrollment if the state Composition receives a report of change for date of death and household composition. Access to Public No Department of Labor Employee Coverage Sources: CMS 2016; Data collection and verification under the 2018 Assessment of Medicaid Eligibility, Enrollment and Renewal Processes and Systems project, Medicaid and CHIP Payment and Access Commission (MACPAC) contract number MACP18417T1. Notes: Acronyms are as follows: MAGI – Modified Adjusted Gross Income, ACA – Patient Protection and Affordable Care Act, N/A – Not Applicable. State Health Access Data Assistance Center 7 Auto-enrollment and renewal Idaho has designed an enrollment process supported by individualized customer service. At least one respondent surmised that this high-touch approach works because Idaho has a relatively small Medicaid program—268,000 individuals in April 2018. While many aspects of the eligibility verification process are automated and draw on electronic data, every Medicaid enrollment requires an action by an eligibility worker. For example, a worker will log into eVerif-I to verify income using the Work Number. Once the worker accesses and verifies relevant electronic information, there is relatively little follow-up with the beneficiary. This reflects similar findings that an estimated 50 to 75 percent of MAGI Medicaid determinations are made within 24 hours (Brooks et al. 2018). For cases requiring additional documentation, the state points to the benefits of prioritizing individualized application support. As one respondent explained, “This is why we value that face-to-face [and telephone application support]. Let's say we can't get a wage verification through any of our interfaces and let's say they say that they're working at Walmart. We will just say ‘Okay, hold on, let's call them,’ and we'll do a collateral call at that moment to get the information so that we can continue the application process and finish it as soon as we can.” Respondents also pointed out that this process is both fast and accurate. Even without auto-enrollment, roughly 90 percent of Medicaid re-evaluations (Idaho’s term for renewal) were described as no touch; this figure was even higher for enrollees in exchange plans (99.9 percent). They have achieved this high auto-renewal rate by creating different workflows and verification requirements for three different types of households (referred to as buckets) and by aligning the timing of re-evaluations for all health care programs to be consistent with open-enrollment. (According to respondents, the state is moving away from aligned renewal timing to ease workloads.)The buckets include: 1) MAGI Medicaid only, 2) families with multiple health coverage types (exchange plan, MAGI Medicaid, and CHIP), and 3) non-MAGI Medicaid. Respondents reported that the distinct workflows streamline the renewal process for both workers and consumers. Supporting these workflows, IBES has a timeline that populates in idalink and explains what steps beneficiaries have taken and what actions (if any) need to be taken and when. Because IBES is an integrated system, it can also leverage information submitted for other programs to support auto-renewal in health care programs. One respondent explained, “The one nice thing is that because our system is integrated, if they [a beneficiary] are also on SNAP benefits, then if they come in for a SNAP renewal that may not be aligned with our Medicaid renewals, if we get new information then we would take that information and apply it for changes for Medicaid.” Respondents acknowledged that they continue to try to strike a balance between automation and program integrity. Therefore, they are planning to scale back the number of cases that receive auto- determinations slightly (by 1 to 2 percentage points). Specifically, they plan to contact beneficiaries who have received a no-touch auto-determination for two or three consecutive years to verify that their circumstances have not changed. One respondent clarified, “We've identified some populations that we want to have a little more contact with. But we rely really heavily on automation to make sure that those buckets we described are defined in a way that we can feel good about the integrity of our program and the accuracy of our determination while also making sure that our staff don't have to touch 300,000 people every year.” State Health Access Data Assistance Center 8 Integration of MAGI Medicaid eligibility determination with other health or human services programs Integration of MAGI Medicaid eligibility determination with other health or human services programs is demonstrated in three ways in Idaho. First, a single administrative structure (the Division of Welfare) supports eligibility determinations for all health and human service programs. Second, one online application—idalink—serves all health coverage programs, including MAGI and non-MAGI Medicaid, CHIP, and exchange coverage (described above). And third, the state uses a single, horizontally integrated eligibility system (IBES) which supports all health and many non-health eligibility determinations. The state has a history of conducting eligibility determinations for health and non-health programs in an integrated way that predates the ACA, and its agency structure supports that. One bureau supports all programs, avoiding the need for duplicative structures to support siloed programs. For example, within the Division of Welfare, the Bureau for Operations Design (with its team of developers, process engineers, policy and operations staff, automation liaisons, and other staff) maintains IBES and manages the logistics of the system changes, staff training, and worker and customer communication supports for all programs. Respondents observed that housing the application, eligibility processes, and customer-facing tools within the Division of Welfare allow the state to have excellent customer service and low administrative costs. One respondent stated, “We get to be really cohesive and really integrated and creative on the application experience. I think we have some of the best customer service in the nation because we're really able to look at that across all programs from a customer's perspective and make processes and policies and standards that make sense. It's also a lot easier for our staff. We have really low administrative overhead because our staff can pretty easily do eligibility for all programs kind of in one system with one set of standards…rather than have these duplicative structures.” Respondents also thought that a single structure is particularly beneficial for families that have coverage in multiple programs. One respondent observed, “Because we didn't expand [Medicaid] and because our MAGI parent limits are so low, we have a lot of mixed families [e.g., a parent with exchange coverage and a child on CHIP]. So I like the opportunity it affords us to give really good customer service around those annual renewals.” Respondents all reported the state’s commitment to supporting an integrated eligibility system with a robust rules engine as critical to achieving the horizontal integration of MAGI Medicaid with other health and human services programs. One benefit of IBES is that it has information on the whole range of health and human services enrollees, which are useful data for operational planning and policy analysis. Respondents also expressed that because IBES supports multiple health and non-health programs, changes to any single program must be viewed “holistically with all of the existing standards and processes that we have in place and really making sure that that change that's being rolled out aligns with everything that we have existing across all programs so that we have consistency for staff no matter what program they're working on.” Respondents noted that the state has worked hard to ensure that IBES, Your Health Idaho, and claims processing are aligned. However, establishing a post-eligibility interface that sends accurate and timely beneficiary information to the Division of Medicaid and Your Health Idaho was initially challenging and has improved over time. During our interviews, these systems were described as “tightly integrated.” One respondent said, “The linking process has really been our primary focus the last couple years, and we've gotten that down to a fairly efficient process. But, early on, that was kind of our Achilles' heel.” State Health Access Data Assistance Center 9 To ensure information fidelity, the state established IBES as the official source of information about the applicant and their eligibility status. As an example, to operationalize this, respondents described the connection between IBES and Your Health Idaho as a “one way street,” meaning that changes to family structure or income are reported through idalink, which is updated nightly in Your Health Idaho. While respondents acknowledged that this batch process is not ideal, they identified it as critical to avoid inaccuracies between the systems. Because beneficiary information is housed in several systems, enrollment assisters observed that beneficiaries must be consistent in how they set up their accounts to ensure that information flows can occur (e.g., identifying the same head of household in both accounts and using the same phone number). Notably, the credentials (i.e., username and password) for the Your Health Idaho account are identical to the beneficiaries’ idalink account, which enrollment assisters identified as an important customer service feature. MEDICAID PROGRAM AND BENEFICIARY EXPERIENCES As described above, Idaho prioritizes a high-touch customer service-focused approach to enrolling individuals in Medicaid and other health and non-health programs. The eligibility functions for health and non-health programs are housed separately from Medicaid program administration, and the Division of Welfare supports a horizontally integrated eligibility system. While the state does not conduct no-touch auto-enrollment, the eligibility system uses electronic data sources and rules engines to process and verify information and achieves a high rate of auto-renewal. Findings in this section summarize key themes, as identified by respondents, related to Medicaid program and beneficiary experiences, including successes and challenges of state approaches. Respondents reported that the high-touch approach and robust rules engines within IBES leads to program efficiencies. Further, they reported that while the state’s implementation of a horizontally integrated system supported by electronic data has not been without challenges, it has streamlined eligibility and renewal, reduced churn, and lowered administrative costs. High-touch customer service led to efficient application process for health and non-health services As noted above, Idaho differs from other states in prioritizing in-person and phone-based application support. Respondents universally agreed that this was the best way for potential applicants to gain access to the full array of health and human services offered by Idaho. Eligibility workers, who support all health and non-health services, are trained to have “informed choice discussions” with potential beneficiaries, outlining all of the services for which they may be eligible. One respondent explained this approach: “It has been amazing to watch. Just watching us really care about the customer who is [in] front of us, really getting the whole story about what their situation is, what's going on in their life, and then trying to match services to their specific situation. I know in this day and age it seems like we always are trying to push people to the web, trying to push people to an electronic solution. And I really admire how Idaho has kind of flipped that. I mean we do have an online application and we do accept those types of formats, but I just see such value in actually just sometimes having a good conversation with a customer and what is their need and how can we serve them.” It is worth noting that the process is still very timely, with 50 to 75 percent of individuals receiving an eligibility determination in real time, which the state considers as within 24 hours of application (see Appendix) (Brooks et al. 2018). Respondents who assist customers described accessing eligibility support through the Division of Welfare as the best way for people to connect with both Medicaid and other services for which they likely qualify. One customer assistance respondent explained, “Most of those patients I work with have State Health Access Data Assistance Center 10 complicated situations. And most likely, if they qualify for Medicaid, they will also qualify for some other state programs, whether it's food stamps or WIC, etc.…So I usually tell them to go straight to the Health and Welfare office because they can do it all in one appointment, one stop. They can kind of get a good handle on all of the programs they would qualify for versus me sitting down with them and just doing that Medicaid application and then saying, oh by the way, also go down to the Medicaid office and apply for food stamps or WIC, etc.…And I have not heard one person come back and say they [the Department of Health and Welfare] wouldn't see me or they didn't have time for me or they were too backed up, they couldn't see me. So, I feel like…our Health and Welfare is fairly accessible for people.” Enrollment assisters also pointed out that personalized support is critical for people who may not have much experience with the internet or who may not have internet access in their home. Robust, horizontally integrated rules engine was critical in supporting high- touch customer service Respondents stated that Idaho’s customer service-focused approach is only possible because IBES’s robust business rules have automated the varied and complex eligibility rules across programs. They detailed how IBES allows the eligibility worker to focus on the consumer and their specific situation, not the minutia of program rules. The process was described as faster, more efficient, and supporting better customer service. One respondent supported the idea that the focus of the eligibility worker is to have “a quality conversation with that customer about whatever their situation is and then relying on our system to be the one to handle all the heavy lifting about what the rules need to be…determine what all the person is eligible for.” Another respondent echoed this, describing her previous role as an eligibility worker: “Back when I was an eligibility worker we used to have a paper application...for all the programs they were completing an application. And then what I was doing was spending a significant amount of time reviewing all of that stuff and checking interfaces and kind of figuring out what my questions would be…all of those things are [now] eliminated…a person will walk in and you have this informed choice discussion where you can say ‘tell me about your situation.’” A couple of respondents also explained that the system supports a quality control step, as well, whereby workers can review with customers how the information they entered was processed and make any needed corrections. However, many respondents described aligning eligibility requirements of multiple programs as challenging. One said, “It does create some policy and logistical challenges that we've had to spend a lot of time kind of reconciling and figuring out how do we come up with one standard for this program that makes sense to staff, makes sense to customers, but also meets all of the various regulations for each individual coverage category. And I'd say that's probably the biggest cost associated with trying to integrate the coverage groups. We think it's worth it…for other states that are looking at moving towards something like our structure, you really need to spend a lot of time comparing policies, comparing verification standards and requirements, comparing QC [quality control] standards and making sure that when you're rolling out processes and standards for your staff, that you're meeting those standards for each of the programs individually.” Another described building the current rules engine this way: “I would say I definitely don't want to downplay how much work it is. I also think it's somewhat dangerous to try to make it easier. Medicaid rules are incredibly complex. When you throw MAGI and non-MAGI and tax credit all together, they are some of the most complex public policy I think that exists out there.” Given these complexities, respondents stressed that the state’s universally trained eligibility workers still need to understand the policy and rules. “They [eligibility staff] do have to have a foundation of knowing for each program what the policies are, what those rules are. Because they do need to do that. Our system, as great as it works, sometimes there's something that happens and we push something out and somebody needs to identify, oh, this may not be working particularly right.” State Health Access Data Assistance Center 11 Electronic data interfaces facilitated high rates of real-time eligibility determinations, auto-renewal, and reduced churn Respondents universally shared the perspective that great efficiencies were gained through system linkages to electronic data sources, which facilitate high rates of real-time eligibility determination and auto-renewal. Specifically, respondents highlighted the state’s connections with the Work Number and SSA as well as the connection with the Federal Data Services Hub. Assisters described the auto-renewal process as “fairly seamless” and affirmed that it has reduced their workload. Respondents at the state remarked that it is more efficient, and reduced churn, both reducing administrative costs and improving continuity of care. One explained, “Not only is there a business perspective, but more importantly, it mitigates the risk of gaps in coverage. That's the single most critical item. So, Sally Consumer is enrolled this year, she's happy. She's got meds, and they're regular meds and they're really important to her, like life threatening, got to have the meds. If she's not auto-renewed, Sally's got to remember to call and renew herself. And imagine if Sally is forgetful and goes to renew her life-dependent prescription the second week of January and says, oh, I forgot; I didn't know that I had to renew my plan….[T]here's some real-world customer impacts that are far more important than the business reasons, but that's a real risk….For Sally who's auto-renewed and is forgetful, she's going to be able to get her meds, she's going to have coverage, and she's going to have quality of life because there's continuity there.” Assisters also praised the integrated eligibility system and use of electronic data to verify information. They noted that it allows them to complete applications more quickly and spend more of their time on complex cases. According to assisters, however, despite robust rules and electronic use of data, verifying income sometimes remains a challenge, and some beneficiaries are required to provide documentation, particularly people with unstable incomes (e.g., individuals who are self-employed, seasonally employed such as farm workers, or frequently change jobs). And, while not all beneficiaries receive a no-touch auto-renewal, respondents highlighted improvements to idalink that support beneficiaries who need to provide documentation, specifically, the electronic filing capacity. One respondent commented: “In the last year or so, we did some upgrades, like I said, to our idalink, so that now people can upload documents and communicate with us through that website. And I do think that that has been helpful. Because before, if they were flagged for a manual reevaluation, then they did have to call us and do like basically a phone interview or come into the office. And now with some of the enhanced e-filing they can actually do those re-evals through idalink. And I think that that has been helpful, especially for people who live in more rural communities.” Combined online application served as a single portal to health coverage, enhanced beneficiary access, and reduced burden While the state prioritizes individualized application support, respondents also praised idalink for those who choose to apply online. One respondent observed that idalink reduces beneficiary confusion, because it serves as an application for all health care programs, saying: “I think the one thing that is great about our idalink application is that we don't specify if you're applying for MAGI or non-MAGI or the tax credit for the exchange. We just call it health coverage assistance. And based on the logic that's built into idalink, if you say that you're disabled, then you're going to be presented with questions for ABD [Aged, Blind, and Disabled or non-MAGI] Medicaid as well as the regular MAGI.” Other respondents felt that idalink supports greater access and reduces beneficiary burden, as it is available at any time and requests information in a streamlined way. Staff at the Division of Welfare reported: “One of the things you can't do is you can't call us in the middle of the night and say hey, I want to apply for Medicaid.…But if you go to idalink, it's a really nice kind of application because it's State Health Access Data Assistance Center 12 smart, the way that it's built. It's based off of what you're saying, what you're telling idalink. Then it knows to ask you other questions. So it's not going to ask you whether you're pregnant if you say you're just a single guy, that type of thing. So it's a smart, tailored application with a really good technology there.” The online application also allows documentation to be submitted electronically. One respondent stated: “[If you have] a family applying for health coverage assistance and going through all of the questions that we need to collect, and seeing that preliminary determination that it will spit out, it will also give them the ability to upload documents. So, it will say we are going to potentially need information about your income, so you can just go ahead and upload that and I can attach it to your application. So that the next day, and this happens actually in real time during the week, once it comes in, it goes into our system automatically and then one of our eligibility workers that's available can just start processing that application.” Assisters also described the application as “fairly simple” and highlighted the fact that Your Health Idaho offered in-person training to assisters which addressed areas of confusion. They also highlighted that the application has a comments or notes section at the end where an assister or individual can highlight a specific situation, a feature that is helpful for applicants with complicated circumstances. LOOKING FORWARD As interviewees reflected on Idaho’s Medicaid enrollment and renewal practices, they were closely monitoring state activities related to Medicaid expansion. Several respondents talked about the coverage gap created by the state’s decision not to expand Medicaid and its effect on potential beneficiaries. Data suggest that roughly 43,000 uninsured adults would be eligible for Medicaid if the state expanded (Garfield et al. 2018). Assisters to whom we spoke mentioned that they frequently encountered people in this gap. One assister said, “I see a lot of gap people [who] I have to give bad news. I'm sorry; you don't qualify for either program, and kind of go over the reasons why. That's a big thing for me.” Others described it as an “unfortunate situation” which influences workload, because instead of simply enrolling the person in one of the state-supported health care programs, they must look for alternative options such as a federally qualified health center that offers services on a sliding-fee scale. Respondents at the state also pointed out that the decision not to expand Medicaid creates many more mixed-coverage families, which are more complicated from an eligibility and renewal standpoint. Respondents also talked about the future of Medicaid in Idaho. While the state legislature has not been supportive of Medicaid expansion, Reclaim Idaho, a volunteer-led community organization, successfully collected more than 56,000 signatures to place a Medicaid expansion measure on the November 2018 ballot (Weixel 2018). Respondents at the state confirmed that they are monitoring the expansion effort and the type of action the legislature might take, noting that some ideas will be easier to implement than others. One said, “[If the ballot measure passes] it's kind of up to the legislature as to how they want to do Medicaid expansion. They can just leave it alone and do kind of a plain vanilla expansion, which would make it real easy for everybody, or they can get creative and say, ‘Yeah, we want work requirements.’ [T]ime limits have been tossed around, although I know that CMS has never approved those.” Across the board, assisters shared that they are extremely excited about the prospect of Medicaid expansion, even if the expansion is non-traditional. One responded, “I would so love to be able to say, ‘Yeah, you don't qualify for traditional Medicaid and you don't qualify for the tax credit, but this expansion has allowed you to qualify for X.’ I would love, love to see that rather than I'm so sorry that you don't qualify for anything. But we'll see. I don't know what will happen, that's for sure, none of us do. But at least it's a possibility.” State Health Access Data Assistance Center 13 REFERENCES Brooks, T., Wagnerman, K., Artiga, S., and Cornachione E. 2018. Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2018: Findings from a 50-State Survey. Washington, DC: Georgetown University Center for Children and Families and Kaiser Commission on Medicaid and the Uninsured. http://files.kff.org/attachment/Report-Medicaid-and-CHIP-Eligibility-Enrollment-Renewal-and- Cost-Sharing-Policies-as-of-January-2018. Centers for Medicare & Medicaid Services (CMS), U.S. Department Health and Human Services. 2018. Medicaid and State Children Health Insurance Program (CHIP): March and April 2018 Preliminary Monthly Enrollment. Baltimore, MD: CMS. https://www.medicaid.gov/medicaid/program- information/downloads/april-2018-enrollment-data.zip. Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services. 2016. Medicaid and State Children Health Insurance Program (CHIP): Idaho Eligibility Verification Plan. Baltimore, MD: CMS. https://www.medicaid.gov/medicaid/program-information/eligibility-verification- policies/downloads/idaho-verification-plan-template-final.pdf. Centers for Medicare & Medicaid Services (CMS), U.S. Department Health and Human Services. n.d. Real- Time Eligibility Determinations for MAGI Populations. Baltimore, MD: CMS. https://www.medicaid.gov/affordable-care-act/provisions/downloads/real-time-determinations.pdf. Garfield, R., Damico, A., and Orgera, K. 2018. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. San Francisco, CA: Kaiser Family Foundation. http://files.kff.org/attachment/Issue-The- Coverage-Gap-Uninsured-Poor-Adults-in-States-that-Do-Not-Expand-Medicaid. Idaho Department of Health and Welfare (DHW). 2016. Facts/Figures/Trends 2016-2017. Boise, ID: DHW. https://healthandwelfare.idaho.gov/Portals/0/AboutUs/Publications/FFT2016_2017.pdf. Leavitt Partners. n.d. The Your Health Idaho marketplace: a model for state based adoption. Cedar City, UT: Leavitt Partners. https://www.yourhealthidaho.org/wp-content/uploads/2018/07/Leavitt-Partners- Study_The-Your-Health-Idaho-Marketplace-A-Model-For-State-Based-Adoption.pdf Shaw, T., Street, L., Gonzoles, S., and Rosenbaum, D. 2015. State Innovations in Horizontal Integration: Leveraging Technology for Health and Human Services. Washington, DC: Social Interest Solutions and the Center on Budget and Policy Priorities. https://www.cbpp.org/research/state-innovations-in-horizontal- integration-leveraging-technology-for-health-and-human. U.S. Census Bureau, Population Division, Department of Commerce. 2017. Annual estimates of the resident population: April 1, 2010 to July 1, 2017. Washington, DC: U.S. Census Bureau. https://factfinder.census.gov/faces/tableservices/ jsf/pages/productview.xhtml?pid=PEP_2017 _PEPANNRES&src=pt. Weixel, N. 2018. Idaho Medicaid expansion ball measure moving forward. The Hill. Apr 30, 2018. http://thehill.com/policy/healthcare/medicaid/385511-idaho-medicaid-expansion-ballot-measure-moving- forward. State Health Access Data Assistance Center APPENDIX PRE-TELEPHONE DISCUSSION DATA COLLECTION FORM State Health Access Data Assistance Center A-1 MACPAC ELIGIBILITY, ENROLLMENT, & RENEWAL PROCESSES AND SYSTEMS STUDY PRE-TELEPHONE DISCUSSION DATA COLLECTION FORM: IDAHO We realize that your agency is extremely busy. In order to maximize our time together on the telephone, we are requesting that you review this form to verify blue text or enter in the blue shaded areas information about your current Medicaid program and supporting eligibility systems. Please make any corrections directly on/in the document. This form should take about 10-15 minutes to complete. 1) Name of Medicaid Agency: Department of Health and Welfare 2) What is the PRIMARY agency responsible for Medicaid eligibility determination at ENROLLMENT if different from Medicaid agency above: same 3) What is the PRIMARY agency responsible for Medicaid eligibility determination at RENEWAL (if different from #3): same 4) Please confirm other governmental or quasi-governmental agencies/organizations/programs that regularly work with the PRIMARY agency above on Medicaid eligibility determination: Agency Name Agency Type Involved at Involved at Enrollment Renewal (Check if yes) (Check if yes) Separate CHIP ☐ ☐ Other State Agencies ☐ ☐ Your Health Idaho State-based Marketplace ☒ ☒ N/A Federally Facilitated ☐ ☐ Marketplace Enter specific areas if not statewide: County or City Agencies ☒ ☒ Regional offices statewide Enter name: Other ☐ ☐ 5) Please verify the maximum monthly Medicaid income eligibility levels in Idaho in terms of the Percent of Federal Poverty Level (FPL) for the following populations for which eligibility is determined based on the Modified Adjusted Gross Income (MAGI) standard. Coverage Group Eligibility Threshold: Percent (%) of Federal Poverty Level Children < 19 185% (including 5% disregard) Adults without Dependents N/A Individual Parents and Caretakers 26% (including 5% disregard) Individual Pregnant Women 133% (including 5% disregard) State Health Access Data Assistance Center A-2 6) Please identify and describe the primary computer or information technology (IT) system currently used by agency staff to support individual Medicaid eligibility determination, re-determination, and/or tracking for Idaho’s MAGI Medicaid populations. System Name: Idaho Benefits Eligibility System (IBES) Year System Implemented: 2010 If not replaced in the last 10 years: Major System Modification? Yes ☐ No ☐ N/A ☒ Year of Major System Modification: Vendor(s) Used for Recent System Replacement/Major Modification: System Statewide: Yes ☒ No ☐ If no, please describe geography covered: --- 7) Please identify the other programs/benefits for which individual eligibility is determined and/or tracked through the primary Medicaid eligibility system named in Question #6 above. Integrated at Integrated at Name of Program/Benefit Type of Program/Benefit Application Renewal (Check if yes) (Check if yes) SCHIP CHIP ☒ ☒ Idaho Medicaid Other Non-MAGI Medicaid programs ☒ ☒ Other non-Medicaid health insurance ☒ ☒ programs (Marketplace, commercial plans, etc.) Food Assistance SNAP ☒ ☒ Cash Assistance TANF ☒ ☒ Child Care Assistance Child care ☒ ☒ Child support ☐ ☐ Enter name: Other non-health programs/benefits ☐ ☐ 8) Please provide an estimate (in Column A) of the timeliness of MAGI Medicaid eligibility determination at application and the extent to which renewal is automated in Idaho. Alternatively, please verify the survey data (in Column B) from the source cited below. A. Percent of B. Percent of Applications Applications (estimate) (Kaiser/Georgetown Survey)* MAGI eligibility determinations are 50-75 completed within 24 hours of application MAGI eligibility determinations are completed within one week of application MAGI cases are auto-renewed (also known 75+ as ex parte renewal, passive renewal, or administrative renewal) *Source: Brooks, T., Wagnerman, K., Artiga, S., and Cornachione, E. 2018. Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost- Sharing Policies as of January 2018: Findings from a 50-State Survey. Washington, DC: Georgetown University Center for Children and Families and Kaiser Commission on Medicaid and the Uninsured. http://files.kff.org/attachment/Report-Medicaid-and-CHIP-Eligibility- Enrollment-Renewal-and-Cost-Sharing-Policies-as-of-January-2018. State Health Access Data Assistance Center A-3 9) Please confirm that the Medicaid/CHIP Eligibility Verification Plan for Idaho on record with CMS is up to date. The date we have for Idaho’s plan is 5/26/16 based on the information found here. https://www.medicaid.gov/medicaid/program-information/eligibility-verification- policies/downloads/idaho-verification-plan-template-final.pdf Is this the most current verification plan? Yes ☒ No ☐ If not, where can we access the current verification plan? Please provide link or attach with date. 10) Please indicate which IT resources are used to support eligibility determination and renewal for Idaho’s MAGI Medicaid populations. MAGI Is this Is this Start Medicaid resource used resource used Information Technology Resources Year only? at application at renewal (Check if yes) (Check if yes) (Check if yes) Multi-benefit/combined online application for N/A ☒ ☒ health insurance programs Multi-benefit/combined online application for N/A ☒ ☐ health and non-health insurance (e.g., food stamps) programs Online eligibility screening tools ☐ ☐ ☐ Self-service case management for clients, e.g., to ☐ ☒ ☒ check application status, report changes, renew Document management or imaging tools for clients, ☐ ☒ ☒ e.g., to support upload and routing Mobile applications for clients ☐ ☐ ☐ Document management or imaging tools for staff ☐ ☒ ☐ Staff portals ☐ ☒ ☐ Navigator/assister portals ☐ ☒ ☒ Business rules engines to automate calculations ☐ ☒ ☒ based on rules and logic Eligibility system interface with MMIS, e.g., claims ☒ ☐ ☐ Other IT resources, e.g., applications/tools, online accounts or portals, system modifications or interfaces Specify other IT resource: Data Services HUB ☐ ☒ ☒ Specify other IT resource: SSA Interface ☐ ☒ ☒ Specify other IT resource: The Work Number ☒ ☒ 11) Of the IT resources listed above, which would you describe as most critical to supporting MAGI Medicaid eligibility determination and renewal? Rank the top three. #1 Data Services Hub #2 SSA Interface #3 The Work Number Thank you for your time! State Health Access Data Assistance Center