Enrollment, Marketing & Outreach for Coverage Expansions

1. Enrollment, Marketing & Outreach for Coverage Expansions The Louisiana Experience State Coverage Initiatives National Workshop New Orleans, LA January 25, 2007 J. Ruth Kennedy La. Dept of Health & Hospitals

2. Overview of Louisiana Strategies • Engaging eligibility employees in outreach, marketing, & enrollment • Successfully reducing procedural closures as renewal • Major organizational change in our eligibility operations

3. The Importance of InformingFamilies Children will not be helped if we don’t intervene. Parents are either unconcerned or unaware. --LA Congressman Rodney Alexander

4. Louisiana Eligibility Administrative Overview • Eligibility is determined by state Medicaid agency employees • Medicaid Analysts process only Medicaid and SCHIP cases • Approximately 50 local eligibility offices • Medicaid Program has direct line authority over 844 eligibility employees

6. Medicaid Eligibility Staff are Major Players in Outreach • 843+ local Medicaid managers, supervisors, eligibility caseworkers, and clerical staff • Brainstorming and implementing Regional Outreach Plans • Organizing and conducting launch meetings • Telling friends, family, neighbors, and acquaintances about LaCHIP • Distribution of application form and holders in their communities

7. Connecting the Dots . . . Why Health Coverage Matters

8. HCFA’s 2000 Summation of LaCHIP Outreach Efforts . . .the State has been both aggressiveand innovative in marketing the program and enrolling eligible children. The state has worked arduouslyin establishing an effective grassrootseligibility outreach network and has taken full advantage of vital partnership opportunities, such as with the Robert Wood Johnson grantee. As a result the State enrolled a significant number of previously uninsured children and exceeded its established enrollment goals. The State has also substantially reduced the number of uninsured children by identifying and enrolling eligible Medicaid children. --Draft Review of Louisiana’s LaCHIP Program Dated 8/16/00

9. Net Change in Monthly Enrollment of Children--Medicaid and SCHIP 14000 12000 10000 8000 6000 4000 2000 0 -2000 -4000 “Houston, we’ve got a problem” -6000 J-99 S-99 D-98 M-99 1-Jun 2-Jun 1-Mar 2-Mar 1-Dec 1-Sep 2-Sep Mar-00 Jun-00 Dec-00 Dec-99 Sep-00

10. A “Hole in the Bucket” or Renewal Woes • New enrollees can be exceeded by closures at renewal • Many closures for “procedural” reasons • Failure to return renewal form • Failure to submit essential verification • Unable to locate • Problem more pronounced for “traditional” Medicaid children

11. “Closing the Door” on Procedural Closures at Renewal Matters • Essential to “maintain the gains” • More costly to process applications than renewals • Protects investment in outreach & marketing

12. Our Recipe for “Closing the Door” on Procedural Closures • Simplify the renewal process • Renewal form • Verification requirements • Ex Parte renewals when possible • Aggressive follow-up when renewal form is not received • Telephone renewals • Automated Voice Response renewals • Web based renewals [Coming Soon!]

13. Spotlight on Retention Began in 2001 A “new name”—name for process formerly known as “redetermination” changed to “renewal” • New simplified Renewal Form • Ex parte renewals mandated for children with active Food Stamp cases • Involved local offices in identifying solutions

14. Ex Parte Renewal Defined • “Action by one party without the involvement of the other” • Described in 4/7/00 State Medicaid Director’s Letter • Heavy reliance on other computer systems for verification • Food Stamps • TANF • Child Support More than 60% of Title 19 Medicaid children are extended 12 months using exparte renewal

15. “Ex Parte” --New Eligibility Vocabulary Word • It’s an adjective! • CMS advised that we should do ex parte renewals. • It’s a verb! • Is there any way you can possibly ex parte it? • It’s a noun! • I did 8 ex partes yesterday.

16. Aggressive Follow-up When Renewal Form in Not Received • Incorporated into policy and procedures since July 2001 • Phone calls must be attempted and documented • Efforts to find new address and locate family • Other computer systems • Internet • Schools, medical providers • Major losses when temporarily discontinued from 7/06 to 11/06

17. Telephone Renewals Benefit Families and the Agency • Federal regulations require annual review—not signed form • Implemented 11/03 as option when ex parte can’t be done • Two types of telephone renewals • In lieu of mailing a Renewal Form • At follow-up when Renewal Form is not returned • Key to our getting procedural closures below 5% • Reduces administrative cost—postage, paper, staff time

18. Automated Voice Response (AVR) Renewals • Families can renew anytime—off-cycle or “rolling” renewals encouraged • Option available when calling the LaCHIP toll-free hotline • “To renew by phone now, Press 3” • Data retrieved daily & electronically routed to local eligibility offices • Reminder flyers advise of this 24/7 renewal option

19. Local Office Involvement in Developing Retention Plans • Participating in workgroup resulted in greater awareness of the problem (education/training) • Front-line staff have unique insights and proposed excellent strategies • Ownership and buy-in was achieved “I think one of the highlights staff enjoyed was being able to come up with a renewal plan, and then watch their ideas at work” -- Debbie Falgout, Medicaid Analyst Supervisor Thibodaux, Louisiana

20. Examples of Local Initiatives to Improve Retention • Supervisory review of all procedural closures at renewal • Not requesting ANY verifications at renewal • Adding a “drop box” outside the building for after hours convenience to return renewal forms, verifications • Additional “reminders” e.g. fluorescent pink reminder flyer prior to advance notice of closure • Enclosing another renewal form/SASE with advance notice of closure • Using US Postal Return Service • Telephone surveys of families who failed to return the renewal form

21. Ongoing Evaluation of Policies, Procedures and Practices • Some policies and procedures have unintended consequences, or in retrospect prove to be unnecessary; • Example: policy to hold renewals and not close them for procedural reasons until deadline day for closures • “Best practices” need to be identified, documented and shared with other offices • Good renewal outcomes by regions and offices deserve acknowledgement and recognition

22. “Organizational Change” Can Be Achieved in Eligibility • A key prerequisite to success of other marketing and outreach efforts • Caseworkers “open” and “close” the door • Major changes in expectations of caseworkers • Passive • Pro-active

23. Training for Managers Regarding Change in Focus • From strong emphasis on quality control, error reduction, thorough case documentation . . . • . . . To removing barriers, making enrollment process “user friendly”, enrolling eligible children and families, assuring loss of cash does not translate to loss of Medicaid as well.

24. How Much is Too Much?

25. “New Thinking” in Local Offices • “What is making a difference is staff has changed their way of thinking and they do bend over backwards to help the recipient. The mindset is that the applicant or recipient is our number one priority. . . .the Analyst continues to extend time when the recipient states he or she needs more time to get the information in. The Analyst will help the recipient to gather information or documentation whenever possible.” --Margo Joseph, Medicaid Area Manager LaPlace, Louisiana

26. Organizational Change“A Long Hard Row to Hoe” “The “old” way of thinking was that if “they” wanted the services “they” should be expected to do the legwork. Now [caseworkers] get forms completed and information verified [themselves], which,in the long run, actually saves time.But changingold habits has been a long, hard row to hoe.”

27. Our “Who Moved the Cheese?” Training Remain Relevant • They have moved the cheese • The quicker you let go of old cheese, the sooner you can enjoy new cheese • They keep moving the cheese so be ready to change quickly!

28. Lessons Learned from our Eligibility Transformation • Incremental changes rather than “big bang” approach” • Dual focus—administrative as well as health & social • Attention to messaging; internal as well as external marketing • Establish high expectations for staff • Empowerment of state government employees • Expect initial pushback

29. Low Income Uninsured Children in Selected States* 2004-2005 • United States 19.3% • Louisiana 12.5%!!! • Mississippi 18.1% • Georgia 18.5% • California 21.6% • Arizona 24.0% • Texas 29.9% • Based on 2006 CPS data (most current information available) and taken from Kaiser • Health Insurance Coverage in America—2005 Update

30. Louisiana Medicaid & SCHIP Enrollment < Age 19 Before Katrina 8/05 Now 1/07

31. “Success isn’t Permanent”Challenge of Sustaining Improvements • Reversals being driven at the federal level— DRA citizenship & identify documentation requirements • Vigilant monitoring of enrollment data • Dramatic & rapid reduction in children enrolled since July 2006 • Ongoing process improvement and adjustments are critically important • Renewal and retention must continue to be a major focus

32. Never doubt that a small group of thoughtful, caring people can change the world Indeed, it is the only thing that ever has !— Dr. Margaret Mead Ruth Kennedy LaCHIP Director & Medicaid Deputy Director Louisiana Department of Health & Hospitals P.O. Box 91030 Baton Rouge, LA 70821-9030 Telephone: 225 342 3032 Fax: 225 342 9508 E-Mail: rkennedy @ dhh.la.gov www.lachip.org