The trusted source for
healthcare information and
Massachusetts is front runner for eligibility streamlining
While many states are just beginning the process of evaluating ways to streamline the Medicaid eligibility process, Massachusetts did so a decade ago. That was when the state first looked into the possibility of developing an electronic application for Medicaid.
"Things accelerated during the 2002 to 2004 time frame, when we had a change in administration and there was a significant reorganization," says Phil Poley, chief operating officer for MassHealth.
For most of the 17 agencies which are part of the state's Executive Office of Health and Human Services, the majority of their beneficiaries are also Medicaid members. "So we decided to make Medicaid, in a sense, disappear as a state agency, and become part and parcel of the secretary's office, and have Medicaid administration happen, when appropriate, within these other agencies," says Mr. Poley.
That led to the development of the state's Virtual Gateway, a web-based portal for people to apply for a variety of services, including Medicaid. "There were legitimate concerns from applicants and those who provide care to them that we had too many doors, and it was confusing," says Mr. Poley. "It was also motivated by a belief that we would save money on our administrative costs."
Also, if providers were able to submit an application on behalf of a patient at the moment he or she arrived for care, many of those individuals would become eligible for Medicaid or another program. Thus, the uncompensated care pool funds would not have to be utilized for those cases.
When the Virtual Gateway first was made available in 2004, people were able to submit an application for several programs. Individuals now can apply for 11 different programs. On the health care side, people are applying for the health care safety net funds, Medicaid, and Commonwealth Care, the state's expansion program covering people at up to 300% of the Federal Poverty Level (FPL).
"What it doesn't do is put you into an eligibility or selection process if you are over 300% of the FPL," says Mr. Poley. "Those are people who are eligible for the Commonwealth Choice program, which is analogous to the exchanges. That is more typically your commercial products that are available." However, most individuals who apply do wind up being eligible for one of the subsidized programs.
Before the state's major health care reforms, a platform was already in place for online applications. After the 2006 implementation, the MassHealth application was simply adjusted to accommodate the questions that Commonwealth Care would need answered by applicants.
"So, in many ways, it was not a separate process we had to develop for applicants," says Mr. Poley. "It was one place this is the application for benefits, period. We added the logos of all our three programs to all of our materials. It was clear to people that they were applying for all potential benefits through one front door."
Face-to-face contact for health benefits is no longer required, except for the Temporary Cash Assistance for Needy Families program. Currently, the breakdown of applications is about 60% electronic and 40% paper.
"Obviously, I'd like to see that ratio be much more electronic. Generally, it takes about 20 minutes to complete a paper application and only nine minutes to complete an application online in the virtual gateway," says Mr. Poley. "On the back end of things, our processing of online applications occurs much more quickly than paper applications."
Here are some factors that state Medicaid directors would do well to consider, says Mr. Poley, based on Massachusetts' experience:
People will need assistance with filling out applications.
Mr. Poley says that the MassHealth Medical Benefit Request is "fairly lengthy and complicated." For this reason, individuals seeking health benefits are directed to sites where health care providers or staff from outreach organizations are available to assist in completing these.
"We have about 4,000 people in the state who have been trained to complete applications, and 240 health centers and hospitals where people can go to submit them," says Mr. Poley. "We have found that is a better way to get a cleaner, more accurate application on the first pass."
Making the application directly available to consumers is a possibility for the future. "I think it would be great to simplify things to the point where we could obtain an application from a person online. But so far, we haven't seen a way that we think would be beneficial to anybody to do that," says Mr. Poley.
Very few applications come in without any assistance, and those that do typically have problems that need resolution. This means it takes longer for the person to get the benefits for which they're eligible.
"The application is well-liked by the provider community, and we don't pay providers to render this assistance. It's in their interest to assist people, since that is the way they get claims paid," says Mr. Poley.
To meet the citizenship and identity requirement, an interface can be developed with the state's Registry of Vital Health Records and Statistics.
"If the applicant is born in Massachusetts and signs a release when they apply, the interface is activated," says Mr. Poley. "In layman's terms, we ask the database if there is a birth certificate, and the answer comes back yes or no." This means that a person no longer has to get a copy of his or her birth certificate and send it in.
MassHealth is currently in dialogue with the state's revenue department about the possibility of using income data for the eligibility and redetermination process, so applicants would no longer need to submit pay stubs to verify income.
"We already get data from them that tells us when people get new jobs, what their quarterly wages are. We use that for program integrity measures," says Mr. Poley. The next step would be to verify income eligibility, both for the initial application and the annual redetermination.
"Those are the sort of things that electronic means of transacting business give us the capability of doing," says Mr. Poley. "This makes it easier for consumers, providers, and ourselves and saves money to be quite honest. We spend a lot of time dealing with pieces of paper, and that costs money."
The risk of fraud is probably decreased.
"We don't think this creates increased risk for fraud. We think if anything, it shuts the door on the risk of fraud," says Mr. Poley.
Since validity checks can be done with online applications, this makes the system more accurate. "If someone mistakenly skips an entry on the paper application, we then send them a letter, asking them to answer the question," says Mr. Poley. "Not only is it costing time and money for us, but it's preventing the person from getting the coverage they're eligible for."
Since applicants are face-to-face with a provider in a health care setting, concern about fraud is diminished. "The way we deal with fraud is maintaining a very good and active relationship with health care providers and other folks who see people who are applying for our benefits," says Mr. Poley.
Applicants aren't required to prove their residency, as some may be living with relatives and may not have a power bill or other documents typically used to prove residency. "That's certainly an avenue where a foreign national can come in seeking health care and not really be eligible for benefits," says Mr. Poley. "We deal with that type of thing through partnerships with Homeland Security, to close the door on folks who might come here seeking health care services they don't deserve."
Information should be shared with providers and applicants.
Once a person is enrolled, the My Account page is made available to health care providers. This lists the members of the household, notices sent to the household, what individuals are eligible for, and demographic information. In March 2010, this was made available to members as well.
To verify the identity of the member, an online self-registration process is used. This is similar to the process used in the commercial sector, with the member asked to answer security questions.
However, this process is utilized only for existing clients, not new applicants. "Obviously, in the commercial world there are good examples of how to do that, and we are looking at those," says Mr. Poley. "But I think our application is at a level of complexity that it really would need to be simplified before we go to that."
Changes should be piloted.
While individuals currently can apply for 11 programs online, in the early stages there were only four or five. "One of the big things that I would say is: 'Start small,'" says Mr. Poley. "We are very big here on piloting things before we put them out to the world all at once. That has been a very successful strategy."
For instance, when the My Account page was put up, it was first piloted through an organization that sees a lot of members, so that problems could be fixed before the larger community saw it.
Things may take longer than expected.
It takes time to get through the various levels of legal and policy review that are required. "Don't think that since it takes X amount of days to build a website, that's how long it will take to put the application online. It's going to take you longer," says Mr. Poley.
The production environment must be scaled and sized appropriately.
"You can't just throw up a website. You have to be ready to support that function in production, so if you take a bunch of traffic on this website, it's not going to grind to a halt," says Mr. Poley. "You have to have a help desk available to navigate problems and all the rest of it."
The issue of households should be considered.
Mr. Poley says that if the program were to redesign its eligibility processes, he would change the fact that Medicaid eligibility is determined at the household level. "This means that for the database at the core level of our eligibility system, the basic unit is households," he says. "And that can create problems."
For example, the My Account page is only accessible to the head of the household the person who signed the application for benefits originally. This means that at the time the application was completed, that individual agreed to the terms and conditions.
"We were advised by our attorney that it would not be appropriate to present information to members of the household who did not sign that release," says Mr. Poley. "I don't know how to solve this problem yet. But if we dealt with people at the person level, even for just managing their data, that would probably be more effective."