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Medicaid challenged to shed "gatekeeper" image, simplify enrollment
To become eligible for Medicaid, an individual might have to visit a welfare office in the middle of the day several times, for a face-to-face interview, and struggle with confusing paperwork in order to prove his or her income. That scenario, however, may soon become a thing of the past.
While Medicaid programs have typically adopted a "gatekeeper" approach to enrollment, a sea change is under way. Beginning in 2014, the Patient Protection and Affordable Care Act will require states to use a "no wrong door" approach. This ensures that individuals will be able to enroll in whatever kind of assistance they are eligible for, by going through the process once.
"If the process of enrollment is made more family-friendly, and more consumer-friendly, that will go a long way toward increasing participation," says Stan Dorn, a senior fellow at the Urban Institute in Washington, DC.
While the vast majority of states are only beginning to analyze the changes that will be needed, a handful of Medicaid programs already have made significant progress. "Two states that stand out are Massachusetts and Louisiana, from different aspects of the process," says Mr. Dorn. "Since enactment of its 2006 reforms, and indeed before that, Massachusetts has done a great job streamlining enrollment. Louisiana has done a fabulous job streamlining retention."
Only one application
Massachusetts has reduced the percentage of residents without coverage to less than 3%. In addition to the individual mandate and the subsidies for coverage, Mr. Dorn says that other less well-known policies have contributed to this successful outcome.
For instance, multiple subsidy programs are integrated into a single system for applications and eligibility determination. One application form is used for Medicaid, the Children's Health Insurance Program, the state's Commonwealth Care subsidy program created in 2006, the state's program to reimburse hospitals and clinics for uncompensated care, and state-funded programs serving immigrant children.
As a consumer, you don't need to worry about which program to apply to. You just fill out the form, send it in, and are told which programs you qualify for. "The Medicaid agency determines eligibility for all these different programs, including those run by different agencies in the state government. So, that has helped greatly," says Mr. Dorn.
Massachusetts also uses data to establish eligibility whenever possible. This means that individuals don't need to complete any application form at all. For example, the state had a previous program for subsidizing hospital care. When data from the state pool showed that somebody qualified for the new Commonwealth Care subsidy, the person was automatically found eligible and didn't have to submit an application.
"About a year and a half after the program got under way, roughly one in four residents had their eligibility for subsidies granted automatically based on data, without any need to complete application forms," says Mr. Dorn.
Another thing that Massachusetts did to streamline enrollment was to engage a network of private agencies to complete applications on behalf of consumers.
"There is a long-standing system of state and foundation support for community-based organizations in Massachusetts," says Mr. Dorn. This helps educate local communities and also helps consumers fill out forms.
"The state also said to hospitals and clinics that they would get no money from the state indigent care funds for patients who did not complete the standard application form," says Mr. Dorn.
That led hospitals and health centers to hire staff to complete applications for consumers. More than half of all successful applications for subsidies were completed by community-based organizations or health care providers, rather than by consumers themselves.
"The vast majority of newly enrolled consumers did not have to fill out paperwork in Massachusetts. That was a very important factor in the state's dramatic progress in reducing the number of the uninsured," says Mr. Dorn.
In Louisiana, when a child on Medicaid comes up for renewal at the end of an eligibility period, the state first checks available data to see if the child qualifies automatically. If available data show a reasonable certainty of continued eligibility, the child is simply renewed. If the data do not resolve eligibility questions, the family is contacted for more information and is encouraged to provide that information by phone.
"Only when all those measures fail is the family required to complete paperwork," says Mr. Dorn. "As a result, less than 1% of children have their coverage terminated for procedural reasons at the end of eligibility periods, which is an extraordinary accomplishment."
At the same time, the state is among the best in the country in its federal track record to prevent erroneous eligibility determinations. "So, Louisiana showed you can maximize coverage available to children and safeguard program integrity, by significantly streamlining enrollment and retention procedures," says Mr. Dorn.
Concerns have been raised that if it's too easy to get onto Medicaid, this increases the likelihood for mistakes and fraud. "But, that is not necessarily so," says Mr. Dorn. "If you base eligibility on hard, objective data, rather than application forms, you simultaneously improve the accuracy of decisions and reduce the burden on consumers."
By using data to renew eligibility, Louisiana increased the percentage of eligible children who got health coverage and reduced the administrative cost of determining eligibility. "It also helped lead to some of the country's lowest error rates, as found by the federal government," notes Mr. Dorn.
"To the extent you can base eligibility on good, solid data, you are protecting yourself from program integrity problems while you are sparing consumers needless paperwork," says Mr. Dorn. "This means more of them complete the process and get coverage."
States are already using data for many things, such as the Income Eligibility Verification System (IEVS), where a sample of the population is checked using data from state workforce agencies, tax records, and other sources. "So, states are moving in this direction from a program integrity standpoint," says Mr. Dorn. "These are solvable problems, but it will take resources and it will take effort. People can't sit back and wait."
Contact Mr. Dorn at (202) 261-5561 or email@example.com.