State official responsible for administering the Medicaid Program

OMB Clearance Number

Interview Guide for MEDICAID State Directors or other MEDICAID application experts

Form Approved

OMB No. ________

Exp. Date xx/xx/2010

This version to be used for programs that do not have questions about homelessness or risk of homelessness on the MEDICAID or combined applications

State: _____________________________________________________

Name of Respondent:________________________________________

Phone number: _____________________________________________

Email address of Respondent:_________________________________

Interview conducted by:_______________________________________

Date of interview: ______/______/______

Month Day Year

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/ocio/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. Alice Bettencourt

NOTE to Interviewer: Review the MEDICAID and/or Combined Application prior to the interview to review the type of homeless data or risk factors for homelessness collected on the application. Also note the date when Abt obtained the application to confirm that it is the most recent version.

Introduction: My name is ___________ and I work for a private, independent research firm called Abt Associates. The office of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services is sponsoring this study. The purpose of the study is to conduct interviews with each state’s TANF and Medicaid program staff to collect information about the type of housing status and/or homeless status data that is collected on TANF and Medicaid application forms. Someone from the Abt study team contacted you in October or November 2006 to obtain a copy of your MEDICAID and/or combined application. Today I’d like to ask some more detailed questions about your applications and the information you collect from program applicants about whether they are homeless and their housing status in general. Neither the study nor this interview is being used to monitor program performance in any way. The information you provide will only be used for the purposes of this study.

A. Confirmation that application on hand is current

1. We collected a MEDICAID application from you (online/via email/copy sent to us) in October 2006. Is that application still in use?

__Yes

__No  When was the application updated? [ENTER DATE]. Could you please fax me a copy of the application that is now in use or direct me to a copy on your website? What has changed on the application from the version we collected in October 2006? [ENTER WEB ADDRESS—INTERVIEWER: INTERVIEW CAN CONTNUE IF CHANGES TO THE APPLICATION DO NOT INVOLVE QUESTIONS REGARDING HOMELESSNESS. INTERVIEW SHOULD BE SUSPENDED AND RESCHEDULED IF CHANGES REGARDING HOMELESSNESS HAVE BEEN MADE TO THE APPLICATION.]

2. [IF WE IDENTIFIED A COMBINED APPLICATION] We collected a Combined benefit application from you (online/via email/copy sent to us) at the same time. Is that application still in use?

__Yes

__No  When was the application updated? [ENTER DATE]. Could you please fax me a copy of the application that is now in use or direct me to a copy on your website? What has changed on the application from the version we collected in October 2006? [ENTER WEB ADDRESS—INTERVIEWER: INTERVIEW CAN CONTNUE IF CHANGES TO THE APPLICATION DO NOT INVOLVE QUESTIONS REGARDING HOMELESSNESS. INTERVIEW SHOULD BE SUSPENDED AND RESCHEDULED IF CHANGES REGARDING HOMELESSNESS HAVE BEEN MADE TO THE APPLICATION.]

3. [IF WE DIDN’T IDENTIFY A COMBINED APPLICATION] As we collected application forms from other states, we learned that many states use a combined application covering several programs, either in addition to or in place of a separate MEDICAID application. Does your state use a combined application for the MEDICAID program?

___No (skip to Section C)

___Yes

B. Clarification regarding use of combined application

4. Is the combined application used instead of a separate application for MEDICAID or in addition to the MEDICAID application?

___Combined application used instead of a separate MEDICAID application (Ask 4a)

1. Does that mean that when an individual applies for MEDICAID assistance they complete only the combined application?

___Yes

___No (please explain under what circumstances the separate application is used) ________________________________________________________________________________________________________________________________________________________________________________________________

___Combined application used in addition to a separate MEDICAID application (Ask 4b)

2. Does that mean that when a family applies for MEDICAID assistance they must complete both applications?

___Yes

___No (please explain under what circumstances the combined application is used) ________________________________________________________________________________________________________________________________________________________________________________________________

___Don’t know  Is there someone else we could talk to, to find out more about how the combined application is used? [ENTER CONTACT INFORMATION].

C. Collection of Housing Status, Homeless, or Risk Factors Data

These questions are used to confirm that the correct set of questions is being asked.

The purpose of this study is to find out whether states routinely collect information about homelessness or risk factors often associated with homelessness for MEDICAID applicants through the regular application process. Examples of items on an application that might indicate homelessness are things like living in a shelter, or having no permanent residence. Risk factors associated with homelessness include things like living with friends or relatives, having an eviction notice, or others.

5. a. What is the typical process for completing an application? Which is the most common way applications are completed? (CHECK ALL THAT APPLY)

____ application completed online

____ application completed in-person at a MEDICAID office

____ application filled out and mailed to the MEDICAID office

____ Other (SPECIFY)

b. Do applicants usually fill out the applications themselves without assistance, or do they receive assistance from an intake worker to complete the application? Which is the most common approach?

____ fill out with assistance

____ fill out without assistance

c. Is the same application used throughout the state?

____ Yes

____ No

d. Other than in the application form, is additional information on housing status collected at other points in the eligibility determination process? If yes, when?

____ Yes (SPECIFY)

____ No

We’d like to ask you some questions to confirm that our understanding of the types of information included on your MEDICAID/combined application is correct and to find out more about how these data are collected and used, and reasons why your state collects this information.

[ENTER RESPONSES FOR 6-8 IN THE TABLE BELOW. REVIEW APPLICATON AND REVIEW DATABASE AND MARK PRELIMINARY RESPONSES FROM THE DATABASE FOR QUESTIONS 6 AND 7 IN THE TABLE BELOW.]

6. When we reviewed your combined benefit application, we found that you collect [READ DATA ELEMENTS FROM Q6 COLUMN] on housing status, homelessness, and homeless risk factors. Is our understanding accurate? Is it correct that you do not collect [READ REMAINING DATA ELEMENTS] on the combined application? [INTERVIEWER: IF STATE DOES NOT USE A COMBINED APPLICATION, CODE AS NOT APPLICABLE.]

7. We also determined that you collect [READ DATA ELEMENTS FROM Q7 COLUMN] on your separate MEDICAID application. Is our understanding accurate? Is it correct that you do not collect [READ REMAINING DATA ELEMENTS] on the separate MEDICAID application? [INTERVIEWER: IF STATE DOES NOT USE A SEPARATE MEDICAID APPLICATION, CODE AS NOT APPLICABLE]

8. If a combined application is used, do applicants for all programs covered by the combined application answer each item? Or are there items that are only required for some of the programs included on the combined application? Please explain. [INTERVIEWER: IF STATE DOES NOT USE A COMBINED APPLICATION, CODE AS NOT APPLICABLE]

Item on application	6. Confirmation that [READ ITEM] is included on your combined application. [Fields should be highlighted in advance based on app review. Code Yes if it is included; Code No if it is not included.]	7. Confirmation that [READ ITEM] is included on your separate MEDICAID application.	8. If combined application is used, do applicants for all programs (TANF, FS, Medicaid, etc) answer the question about [READ ITEM] (if no, please explain)
Housing Status Items
a. Home Address	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
b. Mailing Address	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
c. Directions to home address	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
d. Do you live in public/subsidized housing?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
e. Do you intend to stay in State?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
f. Do you live in a long-term care facility or nursing home?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
g. Do you live in a medical or rehab facility?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
h. Any other questions on housing status? PLEASE SPECIFY	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
Homeless Items
i. Are you homeless?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
j. Do you reside in a shelter?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
k. Are you staying in a domestic violence (DV) shelter?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
l. Do you have a permanent home?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
m. Other Homeless item (PLEASE SPECIFY)	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
Homeless Risk Factors
n. Do you live with friends or relatives?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
o. Do you have an eviction notice?	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
p. Other risk factors? SPECIFY	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No
q. Are there any other items on your application that we have not talked about that are related to housing status, homelessness, or risk factors associated with homelessness? SPECIFY	__Yes __NA __No	__Yes __NA __No	__Yes __NA __No

The responses to these questions will be used to determine which set of detailed questions should be asked. For those programs collecting neither homeless items nor items considered risk factors for homelessness, the “without-homeless data” questions will be asked. For those collecting either homeless or homeless risk factor items, the “homeless data” questions will be asked.

D. Questions for States without Homeless or Homeless Risk Factor Data

9. Do you collect any data on the housing status of applicants at any time other than in the application?

___No (skip to 11)

___Yes

10. At what point(s) do you collect housing status information? Do you collect this information at [READ ITEM]?

Item	Yes	No
a. Prior to eligibility determination (during subsequent interview or home visit with applicant)
b. After eligibility is determined (during an interview or on another form)
c. At recertification
d. Other (SPECIFY)

11. Even if you do not explicitly ask program applicants or participants if they are homeless, do you use any other standard conventions for noting that an applicant is homeless in your database or on application materials? Examples of this might be noting than an applicant is living with family or friends, has not had a permanent address in recent months, note whether an address given is for a shelter, enter 99999 for zip code when homelessness is suspected, etc.)?

____ No [PROCEED TO Q12 BELOW]

____ Yes-- confirm all addresses (would know if address was a shelter)

____ Yes – intake workers are instructed to follow certain protocol (e.g., enter 99999 for zip code) for applicants who are thought to be homeless PLEASE DESCRIBE:

____ Yes – other (SPECIFY)

SKIP TO QUESTION 21 ON HOMELESS DATA VERSION OF QUESTIONNAIRE

12. What would you say are the main reasons your program does not collect such information on the application? [INTERVIEWER: RECORD VERBATIM AND THEN RECODE TO ONE OF THE CODES BELOW. IF MORE THAN ONE REASON CHECK ALL THAT APPLY. PROBE AS NEEDED.]

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___Homeless data or homeless risk factors are not needed to determine eligibility for MEDICAID program

___We have made an effort to streamline application; collecting only necessary information

___Collecting homeless data would be too burdensome (financial or administrative burden is too great)

___Other (SPECIFY)_____________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Has your application (either the combined or separate MEDICAID) ever included any questions on homelessness or homeless risk factors?

___No (SKIP to 18)

___Yes

13. What questions were included? LIST ALL. [PROBE: Examples might be things like “are you homeless?” “do you live in a shelter?”]

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. When were the questions dropped from the application?

________/_________/___________

mm dd yyyy

13. What is the main reason the questions were dropped from the application? [INTERVIEWER: RECORD VERBATIM AND THEN RECODE TO ONE OF THE CODES BELOW. IF MORE THAN ONE REASON CHECK ALL THAT APPLY. PROBE AS NEEDED.]

__________________________________________________________________________

_____Not needed to determine eligibility

_____Not needed to administer the program

_____Too burdensome to collect

______ Other (SPECIFY)

13. When you collected these questions, how were they used in your state?

____ Program and reporting purposes (DESCRIBE)

____ Collected as part of State effort to enhance access to mainstream benefits for people who are homeless

____ Collected to support development or implementation of State Plan to End Homelessness

____ State Policy Academy requested data or uses it

____ Other (SPECIFY)

13. How frequently is your MEDICAID application updated?

____ Monthly

____ Quarterly

____ Semi-annually (every 6 months)

____ Annually

____ Other (SPECIFY)

13. Are these updates seen as an opportunity to add or refine questions on homelessness or housing status?

____ Yes

____ No

13. Do you think that questions related to homelessness or risk factors for homelessness may be added to your application in the future?

___No (SKIP to 26)

___Possibly but not certain

___Yes

13. What are the most likely questions that would be added to the application? LIST ALL.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. When do you think such questions would be added to the application?

13. Are other questions being considered?

___No (SKIP to 26)

___Yes (DESCRIBE)

13. How would these questions likely be used? [INTERVIEWER: RECORD VERBATIM AND THEN RECODE TO ONE OF THE CODES BELOW. IF MORE THAN ONE REASON CHECK ALL THAT APPLY. PROBE AS NEEDED.]

__________________________________________________________________________

____ Program and reporting purposes (DESCRIBE)

____ Collected as part of State effort to enhance access to mainstream benefits for people who are homeless

____ Collected to support development or implementation of State Plan to End Homelessness

____ State Policy Academy requested data or uses it

____ Other (SPECIFY)

13. What is the main reason your state is considering adding questions to the application about homelessness or risk factors for homelessness? [INTERVIEWER: RECORD VERBATIM AND THEN RECODE TO ONE OF THE CODES BELOW. IF MORE THAN ONE REASON CHECK ALL THAT APPLY. PROBE AS NEEDED.]

______________________________________________________________________________________________________________________________________________________________________________________________________________________________

__ To satisfy new reporting requirements

______To increase our involvement with state policy academy (EXPLAIN)

______To address goals (state or federal) regarding ending homelessness and access to mainstream programs for homeless persons

______To facilitate determination of categorical or expedited eligibility for homeless persons

_____ Other benefits or incentives (SPECIFY)___________________________________________________________________________________________________________________________________________

SKIP TO Q27

13. What are the main reasons this type of question is not likely to be added to your application?

_____Not needed to determine eligibility

_____Not needed to administer the program

_____Too burdensome to collect

______ Other (SPECIFY)

13. Is there anything else you would like to add about your MEDICAID application form and information collected from applicants about housing status or homelessness?

Thank you very much for your time and help with this study.

Homelessness Data in HHS Mainstream Programs Abt Associates Inc. 10