Order out of chaos: A simplified enrollment process

Proving again that there are silver linings to the darkest of clouds, those involved with establishing a Disaster Relief Medicaid program in New York City in the hours and days following Sept. 11 are preaching the benefits of the simplified enrollment system they were forced to set up to cope with the situation.

Providing information on the New York experience at this summer’s National Academy of State Health Policy conference in Philadelphia were Deborah Bachrach, an attorney who is counsel to the New York State Coalition of Prepaid Health Services Plans; Kathryn Kuhmerker, State Office of Medicaid Management deputy commissioner; and James Tallon, president of the United Hospital Fund.

Ms. Kuhmerker told a rapt audience that the Disaster Relief Medicaid program was put together in the unheard-of time of eight days to address the immediate health care needs of those affected by the terrorist attacks that brought down buildings in the World Trade Center complex, including the building that housed Medicaid computer communications between New York City and the state Department of Health in Albany. Federal and state waivers of program requirements were needed to permit the rapid response that took place.

An emergency system was needed, she said, because many people had been displaced from their homes and jobs, telecommunications were severely disrupted, and access to the Medicaid eligibility system had been severely compromised.

No backup documents

The emergency program ended up with a one-page application form that called for basic identifying information such as name, how the person could be found again, Social Security number, household size, income, and availability of other health insurance, and did not ask for financial documentation. There was on-the-spot eligibility determination and immediate access to services, and automatic recertification for existing Medicaid enrollees. Coverage under the disaster program was provided for four months. Beneficiaries got the full array of Medicaid benefits but with no nursing home coverage and no managed care.

As the staff now start to look back at what happened, Ms. Kuhmerker says, they are finding that most of the 342,000 people who were enrolled in the four-month period were adults, including many who previously had received Medicaid or public assistance. Enrollees were asked for a Social Security number or to apply for one if they did not have it, and it appears that most people provided accurate numbers. (Possession of or willingness to apply for a Social Security number also was used as a surrogate for legal immigration status.)

Still to be done, Ms. Kuhmerker told the group, is an enrollment process review, demographic analysis, cost and utilization analysis, examination of appropriateness of care, and an analysis of the transition from the emergency program back to regular programs.

Dental care used more

Interestingly, they ended up spending more on dental care than on inpatient hospital care for the four-month period. It seems likely that the heavy promotion of the emergency program brought in people with routine health needs who for some reason had been unwilling or unable to apply for coverage before.

The process undoubtedly was helped by the fact that the state and city already had been working on Medicaid simplification as part of the change from a welfare to a health care program. A single, simplified application already had been developed for a number of programs and community-based enrollers were available to help individuals apply. But before 9/11 there still could be a long wait for eligibility determination and then to access services.

Future efforts to simplify the programs will involve eliminating the need for an in-person interview at renewal, self-attestation on resources, self-attestation on the Social Security number, and a simplified renewal form.

Mr. Tallon said that when people stand back and evaluate the situation, the administrative complexity of public health care programs is "appalling because Medicaid has evolved as the health care component of the welfare system and we haven’t yet taken the welfare out of Medicaid."

He said other state Medicaid programs can learn from the New York experience without having to sustain a major disaster as an impetus. "Sept. 11 imposed a new set of assumptions," he said. "There was no box to think outside of because the box had been blown away."

The effort moved forward, he said, because access to health care was recognized as a major element in the city’s recovery.

Basic outreach worked

Faced with the need for "radical simplification" of the system, he said, outreach moved to bus shelter ads, billboards, and some newspaper ads. With the computer systems in disarray, messengers were hired to move paperwork from one location to another.

Mr. Tallon says that while government officials rightfully have to be concerned about people who may enroll but not be eligible, they also should be concerned about those who are eligible but for some reason don’t enroll. "We designed this program to meet beneficiaries on their own terms," he said, "not for them to meet us on our terms. Beyond the higher income limits, beyond the simplified forms, beyond the limited documentation, a critical feature of this program is that people got their eligibility determination the same day that they applied. At bottom, what made this succeed was a basic and outstanding good customer service. It’s a different way of looking at public insurance programs, and we’d all like to get there."

Maintaining program integrity

Ms. Bachrach reminded the group that in terms of information sought on an application form, very little is required by federal law; most of the fields that need to be completed have come through state or local decisions.

"We’re not saying that you should eliminate everything," she declared. "We’re not saying to throw program integrity out the window. But we’re saying that the Disaster Relief Medicaid experience suggests that there are ways to go in and improve things and streamline the application process."

She highlighted some of the things that can cause problems in the current approach, even in a state such as New York that has a single application for many programs, because the applications are not always processed in the same way.

"If you have a family where one child is in [Children’s Health Insurance Program] CHIP A and another child is in CHIP B, or you have an adult who is going into Family Health Plus and someone else going into Child Health Plus B, you have to photocopy the application. You need original signature pages so you have to get an extra signature page to go with the separate application.

"If you have an absent parent or spouse, you have to answer the questions in the application. You also have to fill out information giving the name, address, and Social Security number of the absent parent or spouse. Does this feel like welfare or does this feel like health insurance at this point?

"Then, if you are a single adult of a couple without children, you have to fill out and answer nine questions on an alcohol and drug-abuse screening form. The nine questions include, In the last 12 months have you ever felt you ought to cut down on your drinking or drug use?’ and, In the last 12 months, have people annoyed you by criticizing your drinking or drug use?’ Talk to my teenage children. If you answer two of the nine questions yes, we have to stop the interview and send you directly to another agency to determine if you may have a drug or alcohol problem. Also, if you are a single adult or childless couple, you have to be fingerprinted.

"This feels like welfare. We need to take some of these requirements and take them off the table. "Keep going through an enrollment packet and you will see there are about six or seven documents we give out in terms of what people’s rights are. It’s more paper. I’m not saying people shouldn’t know all their rights and opportunities. But it’s more paper."

Ms. Bachrach also talked of the amount of time involved currently to get applications completed.

Plans spend more than an hour with each individual helping them complete the application and going through the documents they need to bring in. It can take on average four phone calls, a mailing to the house, and a follow-up visit before everything is assembled to be submitted, she says.

Even with plans using vans equipped with photocopiers and traveling to people’s homes, she says, it can take three weeks to complete an application, and some people never finish. And in 12 months, they’re asked to do it all again. Once the forms are filled out, it can take weeks or months for eligibility to be certified.

"We may not be able to get eligibility determination down to two days routinely, but surely we can do better than seven weeks," she says. And once a person is found to be eligible, it still can be weeks or months until he or she is able to access care.

One of those present, Cheryl Boyce, director of the Ohio Commission on Minority Health, congratulated those involved in the effort and pointed out that what happened was not a system response but a people response.

"I hope the system continues the people’s response," she said. "Is this about insurance or is about people’s need for health care?"

[Contact Ms. Bachrach at (212) 830-7223, Ms. Kuhmerker at (518) 474-3018, and Mr. Tallon at (212) 494-0700.]