Children’s Health Insurance Program Reauthorization Act (CHIPRA) Express Lane Eligibility (ELE)
Supporting Statement Part A: Justification for the Study
CONTENTS
BACKGROUND 1
A. Justification 2
1. Need and Legal Basis 2
2. Information Users 3
3. Improved Information Technology 7
4. Duplication of Similar Information 8
5. Small Businesses 9
6. Less Frequent Collection 9
7. Special Circumstances 9
8. Federal Register Notice/Outside Consultation 10
9. Payment/Gift to Respondents 10
10. Confidentiality 11
11. Additional Justification for Sensitive Questions 13
12. Burden Estimate (Total Hours and Wages) 13
13. Capital Costs (Maintenance of Capital Costs) 17
14. Cost to Federal Government 17
15. Program or Burden Changes 17
16. Publication and Tabulation Dates 17
17. Expiration Date 19
18. Certification Statement 19
REFERENCES 20
ATTACHMENTS
ATTACHMENT A: CHIPRA AUTHORIZING LEGISLATION
ATTACHMENT B: Administrative Cost Discussion Guide
Attachment C: Enrollment Extraction Form (Revised Format)
Attachment D: CASE study protocols of Ele and non-ele programs
D1: Case Studies of ele programs
D2: Case Studies OF non-ele programs
ATTACHMENT E: FOCUS GROUP MODERATOR GUIDES
E1: Focus Group Moderator’s Guide: ELE States (Revised)
E2: Focus group moderator’s guide: non-ELE states (Revised)
Attachment F: 51-state survey instrument
Attachment f1:screen shots, 51-state internet-based survey
Attachment F2: recruiting letter and EMAIL text for transmitting internet-based survey to state officials
attachment G: 30-STATE quarterly interview protocol
ATTACHMENT h: 60-DAY FEDERAL REGISTER NOTICE
ATTACHMENT i: 30-day PUBLIC COMMENT PLACEHOLDER
ATTACHMENT j: CHIPra ele tECHNICAL aSSISTANCE gROUP MEMBERs
ATTACHMENT k: REspondent Materials (consent form, letters, faq)
K.1 advance letter and informed consent form: key informant interviews (case studies and cost/enrollment study)
k.2 focus group participant informed consent form
k.3 51-state survey informed consent form
k.4 quarterly interviews recruiting letter and informed consent form
ATTACHMENT L: CONTRACTOR CONFIDENTIALITY PLEDGE
TABLES
Table 1. Estimated Annualized Burden Hours 14
Table 2. Estimated Annualized Cost to Respondents for the Burden Hours 16
Table 3. Publication and Tabulation Dates 18
As part of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Congress authorized a new policy known as Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or Children’s Health Insurance Program (CHIP) can rely on another agency’s eligibility findings to qualify children for CHIP or Medicaid health coverage, despite their different methods of assessing income or otherwise determining eligibility. As part of CHIPRA, Congress also mandated an extensive, rigorous evaluation of ELE, creating an exceptional opportunity to document ELE implementation across states and to assess the changes to coverage or administrative costs that may have resulted. The evaluation also provides an opportunity to understand other methods of simplified enrollment that states have been pursuing and to assess the benefits and potential costs of these methods compared to those of ELE. The other methods of simplified enrollment being investigated are referred to as non-ELE in this submission.
The Assistant Secretary for Planning and Evaluation (ASPE) within the U.S. Department of Health and Human Services (HHS) will conduct this evaluation and report its findings to Congress. Congress mandated that the evaluation include four key components:
An evaluation of the administrative costs or savings related to identifying and enrolling children through ELE methods compared to the costs of identifying and enrolling eligible but unenrolled children through the State’s regular methods
An assessment of whether ELE improves a State’s ability to identify and enroll eligible but unenrolled children
Recommendations for legislative or administrative changes that would improve ELE’s effectiveness as a method for enrolling or retaining children in Medicaid or CHIP
A report on the percentage of children erroneously enrolled in Medicaid or CHIP based on the Express Lane agency findings
This evaluation will report ELE error rates (item 4 above) but will not calculate them; per CMS’ instruction to States, States will report those to CMS, and we will report those in the Final Report to Congress in 2013.
To carry out a comprehensive ELE evaluation (addressing Congressional mandates 1 through 3 above), ASPE is seeking clearance from the Office of Management and Budget (OMB) to conduct five information collections addressing different aspects of the investigation. These aspects are as follows:
The collection of administrative costs from non-ELE states
The collection of enrollment data from non-ELE states
Case studies of ELE and non-ELE states, including key informant interviews and focus groups in ELE and non-ELE states with parents of children who were enrolled or retained through ELE/non-ELE methods
A 51-state (50 states and the District of Columbia) survey
Quarterly monitoring calls in 30 states
Also, as part of the study, ASPE will collect administrative cost and enrollment data from six ELE states. This part of the study is currently under way because it did not require OMB clearance.
A. Justification
The CHIPRA legislation mandated that an ELE evaluation carry out the following:
Determine if enrolling children through ELE improves a state’s abilities to identify and enroll children eligible for, but not enrolled in, CHIP or Medicaid
Evaluate the administrative costs or savings related to ELE
Determine the extent to which these costs differ from the costs that the state would have otherwise incurred to identify eligible but unenrolled children
Develop recommendations for legislative or administrative changes to improve ELE’s effectiveness.
With roughly two-thirds of the nation’s uninsured children eligible for Medicaid or CHIP but not enrolled (Kenney et al. 2010), the federal government and the states are looking for new ways to simplify the enrollment and renewal processes. As a tool for increasing eligible children’s coverage through Medicaid and CHIP, the promise of ELE has been well identified. For example, using ELE to qualify children for health coverage based on their participation in the Supplemental Nutrition Assistance Program (SNAP), Kenney et al. (2010) estimate that ELE could reach 15.4 percent of eligible, uninsured children. Using ELE to qualify children for health coverage based on state income tax records could reach even more children: an estimated 89 percent of uninsured children who qualify for Medicaid or CHIP live in families who file federal income tax returns (Dorn et al. 2009).
To date, no published studies have rigorously estimated the impact of actual ELE policies on children’s enrollment in Medicaid or CHIP; thus the current study is needed to fill this knowledge gap. Several studies have estimated these effects for other administrative simplification policies, and most have found evidence of coverage gains. For example, Bansak and Raphel (2006) used a pre-post design on the 1998 and 2002 March Current Population Surveys (CPS) and found that policy changes aimed at making it easier for families to enroll and retain coverage for their children (such as eliminating the asset test, offering continuous eligibility and coverage, and simplifying the application and renewal processes) had large, statistically significant positive effects on CHIP take-up. Similarly, Kronebusch and Elbel (2004) analyzed the CPS and found that certain administrative simplification policies, such as presumptive eligibility and self-declaration of income, had a positive effect on Medicaid and CHIP enrollment. In a more targeted and econometrically rigorous analysis, Aizer (2003) examined the impact of community-based application assistance programs in California on Medicaid enrollment using data from 1996 to 2000. Overall, Aizer found that application assistance programs had a large impact on Medicaid enrollment, particularly among Hispanic (4.6 percent) and Asian (6 percent) children relative to other children in the same community.
Authorizing legislation. See Attachment A: Authorizing Legislation, for the text of the CHIPRA legislation, which authorized ELE and the attendant ELE evaluation.
ASPE will use the data collected and analyzed in the CHIPRA ELE evaluation to assess ELE and its contributions to simplifying enrollment and retention processes. ASPE has worked closely with staff from the Centers for Medicare & Medicaid Services (CMS) to understand which ELE programs have been approved, what CMS is most interested in learning from this evaluation, and how this ELE evaluation might fit into the broader research on enrollment and retention simplifications. The two groups have also shared documents extensively; for example, CMS has shared all of the approved State Plan Amendments (SPAs) for ELE, and ASPE has shared the study work plan and included CMS staff in its Technical Advisory Group meetings on the project. Data from the cost and enrollment data collection, case studies, quarterly interviews, the 51-state survey, and other national datasets will be integrated into the analysis. ASPE will collect the following types of data:
Administrative cost data from non-ELE states. Using an Administrative Cost Discussion Guide (Attachment B), ASPE will collect data from state administrators. ASPE will also work with states to develop a flow chart depicting the changes to the enrollment process with the introduction of a non-ELE approach. The discussion guide will allow us to identify the change in costs associated with each change in the enrollment process introduced by the non-ELE simplification being studied. This data collection will help answer a key research question: What other approaches or processes do states have in place to identify potentially eligible children, and streamline eligibility and enrollment for Medicaid, CHIP, and other publicly subsidized health insurance programs? How do these simplifications compare to ELE in terms of administrative costs and effects on new enrollment ?
Enrollment data from non-ELE states. Using an Enrollment Extraction Form (Attachment C), ASPE will collect data from state administrators. (Per the study design, this same data collection form was used in six of the ELE states, those approved for ELE as of December 2010; given the number of interviews, we did not need to seek OMB clearance for the ELE interviews, which were conducted between January and March, 2012.) We will ask the states to populate the form with aggregated enrollment statistics. This data collection likewise is aimed to support answers to the research questions, What other (non-ELE) approaches or processes do states have in place to identify potentially eligible children, and streamline eligibility and enrollment for Medicaid, CHIP, and other publicly subsidized health insurance programs? How do they compare to ELE?
Case studies of ELE and non-ELE states. The case studies are designed to help answer three key research questions:
What ELE practices seemed most promising as methods to easily enroll and retain children in Medicaid and CHIP? What barriers to enrollment and retention remain in these states? Were any methods identified that might be worthy of further evaluation or that might be implemented more widely?
What other approaches or processes do states have in place to identify potentially eligible children, and streamline eligibility and enrollment for Medicaid, CHIP, and other publicly subsidized health insurance programs? How do they compare to ELE?
What are emerging, promising practices for implementing outreach and streamlined enrollment programs and activities to facilitate identification and enrollment of eligible children into Medicaid and CHIP?
Key informant interviews. To conduct the case studies, ASPE will develop interview protocols that will allow for thorough, consistent data collection across ELE (Attachment D1) and non-ELE (Attachment D2) sites. Protocol sections will correspond to the major topic areas for the evaluation, including the following:
Medicaid and CHIP program features related to applications, enrollment, retention, and outreach
ELE/non-ELE policy development and implementation
Outcomes (intended and unintended) related to the ELE/non-ELE program
The role of ELE in federal health reform coverage expansions
Lessons learned and best practices regarding identifying and enrolling eligible children in Medicaid and CHIP through ELE or the alternative non-ELE approach
Key informant interview participants will include state officials responsible for administering CHIP and Medicaid, including the following:
Program directors
Eligibility policy chiefs and other key staff
Express Lane partner agency officials
Key legislative staff, such as the chair of the state legislature’s health committee
Family and child advocates
County social services administrators
Frontline eligibility workers
Community-based organizations involved with outreach and application assistance
We plan to interview approximately 15 key informants per state. By their nature, key informant interviews (and focus groups as well) obtain information from a relatively small number of individuals and thus cannot be presumed to represent the entire population of interest. For key informant interviews, we will work closely with well-known contacts at the state and local level to identify persons and organizations that hold the greatest promise for providing us with exposure to a broad and representative range of stakeholders, but we acknowledge that we may inadvertently miss important individuals and/or perspectives.
Focus groups in ELE and non-ELE states. ASPE will develop moderator’s guides for use in ELE states (Attachment E1) and non-ELE states (Attachment E2). Participants will be parents of children who enrolled or renewed coverage through ELE or the non-ELE pathway of interest in a non-ELE state. The focus group moderator’s guides are designed to elicit individual perspectives on enrollment experiences, access to care, outreach, the Affordable Care Act, and lessons learned about the eligibility and enrollment processes in the state. (Regarding the Affordable Care Act, if findings from the evaluation suggest ELE is an easy route for families to enroll or re-enroll their children’s health insurance coverage and saves States processing time, then ELE holds potential as a method for identifying and enrolling adults into coverage in 2014, be that into Medicaid or the Exchanges. Given that, we are taking the focus group opportunity to ask (1) if the parent has coverage or coverage is something they would look forward to having, and (2) if they have no coverage now but would welcome it in the future, would it be easier for them if they could enroll “automatically” through ELE, the method through which their children enrolled.) Open-ended questions will be organized and structured to address the research questions.
To recruit focus group participants, we will ask participating states to provide two randomly generated lists of families whose child was enrolled or retained through the ELE/non-ELE path in the past six months. Each list shall pertain to a zip code (either near the capital or near the secondary site the team will visit). Recruiters will invite potential participants to take part by phone using a focus group script (approved by an Institutional Review Board) that informs them of the nature of the focus group, the amount of time needed to participate, that they will be compensated, the location of the group, and a contact name and number for more information (scripts for recruiting are now found at the end of Revised Attachments E.1 and E.2). Because we are focusing on parents living near certain localities that we are visiting, the participants in the focus groups are not be representative of all experiences of enrolling or renewing through the ELE/non-ELE path in the state. Still, our qualitative approach will allow us to obtain a broad picture of the ELE/non-ELE path of interest and its impacts on families across each state and in selected localities which can be used to supplement and help interpret the quantitative findings (which are representative of the entire population).
51-state survey. To provide a comprehensive census of all state enrollment and retention simplification activities, ASPE will collect information from all Medicaid and CHIP program directors in 50 states plus the District of Columbia (Attachment F). (Attachment F.1 includes screenshots from the online survey.)We expect there to be 68 total respondents: there are 17 states with separate CHIP programs, which require us to survey both the separate CHIP program director and the Medicaid director for a total of 34 respondents in those 17 states; plus a single respondent in the remaining 34 states. The purpose of the 51-state survey is to conduct a census survey of CHIP and Medicaid program administrators in all 50 states and the District of Columbia about specific state policies related to enrolling and retaining low-income children in the Medicaid or CHIP programs. It will provide the first comprehensive catalogue of all states’ (1) outreach methods (for example, by mass media, direct marketing, use of community partners, use of providers to do outreach, among others), (2) use of third party data to identify potentially eligible children (and if so, which third party data is used, challenges using that data, etc.), (3) outreach strategies likely to be employed in Medicaid in 2014 for the adult expansion population and collect data on reasons why those outreach strategies have been selected, (4) simplification strategies used for enrollment and (separately) for retention, separately in Medicaid and in CHIP, as well as document each state’s use of simplifications in processing steps at application and renewal, and will ask about the impact of those simplifications on increasing enrollment and improving administrative efficiency of cost savings, if those aspects have been assessed by the state, and (5) status of Express Lane plan amendments (approved, implemented, under review, etc.) and documenting reasons why states have or have not applied for approval to undertake ELE. ASPE will email a personalized request to the Medicaid and CHIP program directors requesting their participation in the web survey. We will implement the web instrument using a custom-designed internet-based survey running on a Dataweb platform. The structural design of the survey in Dataweb will enable us to compile responses in a database.
Monitoring state planning, implementation, and operations activities. ASPE will create a protocol for quarterly interviews for key informants in 30 states (Attachment G). We will conduct 30 key informant interviews on a quarterly basis over a 13-month period for five total interviews with 30 key informants.1 The intent of the quarterly contact with the state is to track progress throughout the study period, but because we recognize that individual policies may not change that quickly in the states, the quarterly call guides rotate topics and keep the length of the calls abbreviated. The purpose of the quarterly monitoring calls is (1) to provide federal policymakers with up-to-date information on the state policy context in 30 non-ELE states regarding CHIP and Medicaid existing and planned enrollment and retention simplifications, (2) to understand state-reported implications of those policies on enrollment and costs (if known), and (3) to understand challenges and successes related to states’ policy decisions about enrollment and/or retention simplifications. This information will be gathered through ongoing document review of published information as well as through quarterly interviews with a key policy official in 30 states (the 30 states will exclude the 14 case study states, to minimize burden for the states participating). The data collected through this task will enable the evaluation team and policymakers (1) to understand and assess ongoing policy developments, (2) to fill in knowledge gaps about simplification approaches, challenges, and successes, (3) to identify state trends in enrollment and retention policies, and (4) to inform the recommendations for legislative or administrative changes that would improve the effectiveness of enrolling children through the reliance on findings of ELE partner agencies that Congress identified in the CHIPRA legislation that authorized ELE (P.L. 111-3 Page 123 STAT. 47]. Before each call, the study team will email a list of approximately 10 questions to the key informants. Questions will be tailored to each state’s policy context. We expect the calls to average 25 minutes, based on pre-test results. (We have attached separate protocols in Attachment G for the interviews in quarters one through five.)
We will synthesize the information gained through the collections and produce both an interim and a final report for Congress. We will also provide a set of recommendations on (1) administrative and legislative changes that could be made to improve ELE’s effectiveness and (2) the best outreach and simplified enrollment practices for children under Medicaid and CHIP, whether ELE or non-ELE approaches.
The CHIPRA ELE Evaluation will comply fully with the Government Paperwork Elimination Act (Public Law 105-277, Title XVII) by employing information technology efficiently to reduce burden on respondents. ASPE has selected widely used and easily accessible programs for the information collections. ASPE will use Microsoft Excel to design data collection and abstraction tools for state officials to populate with aggregated administrative cost data and enrollment statistics (the Excel version is identical to the Word version, which was provided for ease of viewing in Attachment C, but we have replaced this with the Excel version). A Dataweb program (posted on a secure internet site) will be used for the 51-state survey data collection. Screenshots can be found in new Attachment F1. All Medicaid and CHIP program directors, in both ELE and non-ELE states, including the District of Columbia, will be given personal, password-protected access to the web data collection program via personalized email messages. We are planning to recruit state officials using an email transmitting the survey link; this email text can be found in Attachment F.2 Collecting information using case studies, focus groups, and quarterly monitoring will not involve use of information technology.
This study is unique in the sense that we found no other current surveys with extensive questioning about state views on ELE issues. While states do submit some, but not all, of this data to CMS already, for example through the CHIP Annual Report Template System (CARTS), the data is not collected systematically or completely by CMS or other sources. For example, CARTS reporting is voluntary in nature, and because of its length (about 122 pages long, requesting information on over 250 data elements as well as additional narrative responses), many States submit incomplete reports. Moreover, this data is not easy to synthesize given its length and format.
There may be concern that some of the data collections in this evaluation could overlap--in particular, the concern as to whether the 51-state administrators survey and the 30 state quarterly calls might overlap or duplicate effort-- and whether it would be possible to enhance one of these collections and eliminate the other. These two data collections are complementary but distinct. The former, the 51-state survey, will provide a comprehensive census of state activities related to outreach, enrollment and retention simplifications employed and effects on costs and enrollment in Medicaid, CHIP, or both, and to understand state views on the challenges and advantages of ELE methods (whether administrative, legislative, financial, systems-related, or for other reasons). The latter data collection effort--the quarterly calls with 30 state respondents--will provide ongoing insight into state policy decisions regarding simplification implementation, as well as understand challenges and successes related to policy decisions regarding simplifying the enrollment and/or renewal processes. This data (the quarterly calls) will be collected five times, beginning in July 2012 and running on a quarterly basis through July 2013. It is not intended to provide a catalogue of what states are doing at a point in time (as the 51 state survey is doing) but rather to track and assess ongoing policy change and trends at the state level.
Although other surveys address some of the same issues as we do in the ELE study (namely issues related to enrollment, retention, and outreach), ASPE has avoided duplication of effort in all study instruments through reviewing and adapting questions about these issues from the following surveys and protocol guides:
The Kaiser Family Foundation’s 50-State Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost Sharing Practices in Medicaid and CHIP (2010-2011 and 2011-2012 versions)
The ASPE-Sponsored CHIPRA 10-State Evaluation Case Study and Focus Group Protocols
The CHIP Annual Reporting Template (CARTS) for 2010
The Kaiser Family Foundation/HMA Medicaid Budget Survey for FY 2011/2012
The Kaiser Family Foundation/Center for Budget and Policy Priorities Survey of Online Applications for Medicaid and CHIP
Case studies, site visits, and focus groups. Because ELE is a new strategy under study, there were few site visit and focus group resources from which to draw. We did adapt some protocol questions developed for a Robert Wood Johnson Foundation ELE case study in Louisiana. Also, we reviewed case study protocols and focus group moderator guides from ASPE’s CHIPRA 10-state study and adapted some questions on enrollment, applications, and outreach.
In addition, ASPE is sponsoring a separate evaluation (the CHIPRA 10-state study) that will involve some overlap with some respondents in this study. For example, that study also has a 51-state administrator’s survey, but with a primary focus on Affordable Care Act issues. We will share instruments to ensure questions on data collection instruments are not duplicated.
The respondents and participants in this evaluation will include key informants and program directors from Medicaid and CHIP agencies, families enrolled or renewed in Medicaid and/or CHIP through ELE and non-ELE methods, and state and local Medicaid or CHIP officials. ASPE will not be contacting any small businesses, thus there is no impact on this community.
Most CHIPRA ELE evaluation information collections—the non-ELE administration cost and enrollment data, the case studies, focus groups, and the 51-state survey—will take place one time only. Each respondent will be interviewed or attend a focus group one time only as well. The quarterly calls will take place over 13 months, and the 30 respondents will be interviewed 5 times (once per quarter), with the first interview lasting up to one hour in length, but subsequent interviews planned for a length of 15 minutes. No plans have been made to replicate the evaluation in the future. Additionally, there are no technical or legal obstacles to reducing respondent burden.
No special circumstances apply.
The 60-day Federal Register Notice (Attachment H) was published in the Federal Register on February 2, 2012, volume 77, No. 22, pp. 5253 - 5254.
Public comments. There were no public comments to the 60-day Federal Register Notice. We have reserved Attachment I as a placeholder for any comments based on the 30-day Federal Register Notice.
Consultation outside the agency. ASPE convened a Technical Advisory Group (TAG) on November 30, 2011 to discuss the study design. Meetings with the TAG will continue as additional critical topics arise. Notably, the TAG will review and consult on the preliminary findings from the administrative cost and enrollment data analysis for ELE states. In addition to ASPE staff (Rose Chu, Nancy De Lew, Kenneth Finegold, Rick Kronick, and Carrie Shelton), the TAG consists of the 11 additional members including state and federal government officials and thought leaders from private and nonprofit sectors. Attachment J lists the members along with their affiliations and degree(s).
a. Focus Group Respondent Payments: ASPE recognizes the time burden placed on the focus group participants, particularly with the population from which ASPE will recruit. These participants will be parents of children who were enrolled or whose eligibility was renewed via ELE programs for the ELE states as well as parents of children who have recently enrolled in public insurance or who are eligible but not yet enrolled. Each focus group takes two hours; participants must leave their homes, travel to another site, and perhaps employ child-minders (although we are planning to either contract with child-minders on site to reduce this burden or to provide a small child-care stipend to participants).
Consequently, we have allocated $50 (in the form of a gift card) as a respondent payment for each focus group participant. This amount, and the type of reimbursement, was based on our recent experience recruiting for focus groups in federally-sponsored projects over the last two years with a similar population (parents with a child enrolled in Medicaid or CHIP), similar focus group length (90 to 120 minutes), and similar type of information collected (experiences with coverage, application, enrollment, retention, etc.). This experience indicates that (1) although gift cards are viewed as a less desirable incentive compared to cash, they do not trigger any income issues that might jeopardize participants participation in or eligibility for public programs, and (2) given the costs of travel and often, child care, a participant must invest, as well as spending 90 to 120 minutes at the group, a $50 payment level is needed to provide enough incentive to participants to attend. We have received IRB approval for using gift cards for the focus groups.
If the expected 10 participants attend the focus group for which they were recruited, the project would incur $12,000 in respondent payments (12 states x 10 participants per group x 2 groups x $50). Given that Congress allocated $5 million for the evaluation of ELE, and that this aspect of the study is the only one that will bring in family voices, we believe the cost is minimal compared to the contribution families’ insights will bring to the study.
b. State Payments: State payments are intended to make states “whole” for participating in this project: that is, the payments are intended to reimburse states fairly for costs incurred to participate in the costs and enrollment portion of the study, including participating in interviews, collecting data, spending programmer time to complete required enrollment tabulations, etc. They are not intended to serve as an incentive to participate. We worked to estimate the number of hours for various staff levels that would be required to complete each data collection effort, and to translate those hours into dollar amounts based on experience working with states on similar data collection efforts.
We therefore plan to reimburse the non-ELE states participating in a single data collection of administrative cost and enrollment data as follows:
$5,000 for participating once in the program costs data study. This reimbursement covers the following tasks: describing standard enrollment processes and associated costs in detail; describing non-ELE path of interest enrollment processes and costs in detail; start-up costs associated with non-ELE path of interest; and the differences in time and direct expenditures associated with a non- ELE path of interest application compared with standard application processes. The State also will review the Research Team’s summary of enrollment process changes and associated costs and savings, based on the above consultations, and to provide any comments and data that are otherwise missing from the summary. Staff whose input might be requested include those working in policy, eligibility, information technology, and human resources.
$30,000 for participating once in the enrollment study. This reimbursement covers the following tasks: providing aggregate monthly non-ELE enrollments and traditional enrollments for children who primarily qualify for Medicaid or CHIP on the basis of income (rather than disability, foster care status, and so on), demographic characteristics including the child’s age, race/ethnicity, primary language, citizenship status, household income, and urban/rural status), past enrollment records for a period of prior public coverage in Medicaid or CHIP, all in Microsoft Excel file formats (table shells are in Attachment C). Primarily this task will involve the work a data programmer, who will be needed to compute all the data runs required.
In the event the state can document additional costs beyond the total of $35,000, ASPE can make some additional funds available to reimburse for the time and resources expended on the cost and enrollment studies.
Mathematica has embedded protections for privacy and confidentiality in the study design. The information collection will fully comply with all respects of the Privacy Act, which protects records that can be retrieved personal identifiers such as a name or other identifying information. Electronic files containing information obtained through all study components will be stored on a secure network with appropriate safeguards to prevent any unauthorized access. Handwritten and hardcopies of interview notes will be kept in locked file cabinets when not in use. Individuals and agencies will be advised of the privacy of their replies under Federal law under section 934 (c) of the Public Health Service Act, 42 USC 299c-3(c). Below we define how each different group we are interviewing will be treated.
Focus group participants will be told at recruitment (a copy of recruiting script is at the end of Attachments E. 1 and E.2) that to protect their privacy and the privacy of all participants, all of the information that they will not be personally identified in any report or publication of this study; that recordings from each focus group will be stored in a project password protected folder that can only be accessed by the study's research team; that focus group notes/summaries will be locked in a file folder in a locked project office; and that if they agree to participate in this study, they must also agree to not share other focus group participants’ names or remarks with others outside of this group, so that their privacy is also protected. They will also be told at recruitment and again at the focus group that their participation is voluntary, and that there is no known risk or benefit to them for participating.
Key informants interviewed for the (1) the cost and enrollment discussions in non-ELE states, (2) the 51-state survey of Medicaid and CHIP directors, (3) quarterly interviews, and (4) the 14 case studies will be informed similarly that we will not personally identify them in any report or publication of this study without their prior permission; that we will not quote them in our reports without their permission, that recordings from each interview will be stored in a project password protected folder that can only be accessed by the study's research team; that interview notes/summaries will be locked in a file folder in a locked project office; that records can be opened by court order or produced in response to a subpoena or a request for production of documents, and that we will keep any records that we produce private to the extent we are required to do so by law; that records will be destroyed after the completion of the project by deleting them from the password protected project folder on the evaluation team’s research network; and that all documents created from the interview will be shredded after the end of the project. However, data from all of the key informant interviews will be reported at the state level (as well as any aggregate statistics we might develop, for example from the 51 state survey or quarterly interviews). For example, each of the 14 case studies will culminate a state-specific report on the implementation of ELE or the non-ELE simplification of interest; the data collected as part of the cost and enrollment study will be reported in a single report, but by State; and the 51-state survey will result in a report in which the states can be identified as to whether or not they have implemented various simplifications.
Attachment K.1 contains the case study advance letters (for ELE and non-ELE states) and consent forms for key informants interviewed through case studies and for cost/enrollment study; Attachment K.2 includes the focus group participant informed consent form (the recruiting script can be found in E.1 and E.2; there is no advance letter sent to focus group participants); Attachment K.3 includes the 51-state survey informed consent form (the recruiting letter can be found in Attachment F.2); and attachment K.4 includes the recruiting letter and consent form for the quarterly interviews.
Finally, ASPE is seeking Institutional Review Board (IRB) clearance from Public/Private Ventures (P/PV) in Philadelphia, PA. The IRB package was submitted to P/PV on March 21, 2012, for review at their April 19, 2012 meeting and IRB clearance was given by P/PV on May 30, 2012. The IRB sought minor changes to the focus group recruiting script (the IRB-approved version can be found in Revised Attachments E.1 and E.2), and specified that we should not offer cash to focus group participants but instead offer gift cards (which we will implement).
.
None of the data collection forms contain items considered to be of a sensitive nature.
ASPE estimates the following burden hours based on budgeted length of quarterly monitoring call, site visit interview, or focus group. ASPE conducted a pretest of the 51-state survey instrument and the 30-state quarterly interview and made revisions based on the results. (The pretest reports are attached to Supporting Statement Part B as Attachments N.1 and N.2.) The final 51-state instrument averaged 30 minutes per complete. The final 30 state quarterly call guides averaged 24 minutes to complete.
Table 1. Estimated Annualized Burden Hours
Type of Respondent |
Forms |
Number of Respondents |
Number of Responses Per Respondent |
Average Burden Per Response |
Total Burden Hours |
Key Informants |
Administrative Cost Discussion Guide (Attachment B)
|
18 |
1 |
1.5 |
27 |
State-Level Computer Programmers |
Enrollment Extraction Form (Attachment C)
|
6 |
1 |
40 |
240 |
Key Informants (ELE States—State- and Local-Levels) |
ELE Case Study Protocol (Attachment D1)
|
120 |
1 |
1 |
120 |
Key Informants (non-ELE States— State- and Local-Levels)
|
Non-ELE Case Study Protocol (Attachment D2) |
90 |
1 |
1 |
90 |
Focus Group Participants (2 Focus Groups in 8 ELE States and 2 Focus Groups in 4 non-ELE States= 24 Focus Groups)
|
Moderator’s Guide (Attachments E1 and E2) |
240 |
1 |
2 |
480 |
Medicaid and CHIP Officials
|
51-State Survey (Attachment F) |
68 |
1 |
.50 |
34 |
Key Informants (Quarterly Monitoring Calls)
|
Quarterly Interview Protocol (Attachment G) |
30 |
5 |
.4 |
60 |
Total Burden |
|
|
|
|
1,051 |
ASPE used the Department of Labor website to determine the annualized cost to respondents; these figures are displayed in Table 2 below.
Table 2. Estimated Annualized Cost to Respondents for the Burden Hours
Type of Respondent |
Total Burden Hours |
Hourly Wage Rate |
Total Respondent Costs |
Staff for Administrative Cost Data Collection
|
27 |
$43.96 |
$1,187 |
Staff for Enrollment Data Collection
|
240 |
$34.32 |
$8,237 |
State-Level Key Informants (ELE States)
|
64 |
$43.96 |
$2,813 |
Local-Level Key Informants (ELE States)
|
56 |
$18.89 |
$1,058 |
State-Level Key Informants (non-ELE States)
|
48 |
$43.96 |
$2,110 |
Local-level Key Informants (non-ELE States)
|
42 |
$18.89 |
$793 |
Focus Group Participants
|
480 |
$16.27 |
$7,810 |
Medicaid and CHIP Officials
|
34 |
$43.96 |
$1,495 |
Key Informants (Quarterly Monitoring Calls)
|
60 |
$43.96 |
$2,638 |
Total |
1,051 |
-- |
$28,141 |
We used information from the Bureau of Labor Statistics (BLS) to calculate median hourly wages for various job levels. Positions for state-level key informants, Medicaid and CHIP personnel, and key informants for the quarterly monitoring calls were calculated at $43.96, the bureau’s median hourly wage for management occupations. State-level programmer wages were calculated at $34.32, BLS’s median hourly wage for computer programmers. Local-level key informant wages were calculated at $18.89, the bureau’s median hourly wage for all community and social services positions. Focus groups will be conducted with (1) families of children whose eligibility was established or renewed through ELE methods and (2) families of children enrolled or renewed through non-ELE routes. We calculated the average wage for these respondents at $16.27, the published BLS’s median hourly rate over all occupations.2
There are no capital and start-up costs to respondents associated with this data collection.
The evaluation will take place over a two-year period. The total cost of the evaluation to the government is $4,687,070. ASPE determined the annualized cost to be $2,343,535 per year by dividing the total funded amount by two years. The total evaluation cost was based on the contractor’s budget that calculated wages and hours for all staff, all mailing costs, telephone charges, travel costs, respondent payments, and overhead costs per contract year.
In addition to the evaluation costs, there are personnel costs of several federal employees involved in the oversight and analysis of information collection that amount to an annualized cost of $36,000 for such labor. The total annualized cost for the evaluation is therefore the sum of the annual contracted evaluation cost, $2,343,535, and the annual federal labor cost, $18,000—a total of $2,361,535 per year.
This is a new data collection.
We will analyze, report, and disseminate the collected information. In the table below (Table 3), we review each planned report and its timing and have specified dates in relation to the OMB clearance expected date—June 22, 2012.
Table 3. Publication and Tabulation Dates
Data to Be Collected |
Planned Start Date |
Planned End Date |
Planned Reporting Date |
Type of Report |
Critical Date by Which Collection Must Begin |
Case study data (key informant interviews and focus groups) and analysis of costs and enrollment in non- ELE states |
August 2012, five weeks after clearance expected, we will begin scheduling first visits. (Scheduling cannot begin until clearance received.) |
March 30, 2013 (39 weeks after clearance expected) |
October 15, 2012-April 12, 2013 (17-42 weeks after clearance expected) |
Each of the 14 case studies will have a separate, state-specific report that synthesizes data gathered. In addition, data from these will be incorporated into a final report to Congress. |
To meet the report to Congress due date, data collection must begin no later than 10 weeks after the expected clearance date of June 22, 2012. |
51-state survey |
July 13, 2012 (3 weeks after clearance expected) |
September 1, 2012 (10 weeks after clearance expected) |
September 28, 2012 |
A memo of findings will summarize data collected; in addition, data will be incorporated into a final report to Congress. |
This data collection could begin as late as 10 weeks (September 1, 2012) after the expected clearance date of June 22, 2012. We would not want to go any later because we would like to exit the field prior to the November elections and November and December holidays, and prior to a planned ASPE-sponsored survey on Affordable Care Act implementation issues of the same respondents planned for January 2013. Consequently, we would like to be out of the field by November 1, 2012 at the latest. |
30 state quarterly monitoring calls |
June 28, 2012 (one week after clearance is expected) |
July 30, 2013 |
Quarterly internal memos, beginning September 2012 |
Internal, quarterly memos on findings |
If OMB clearance is not received by June 22, 2012, the schedule for this would be delayed, but there is no critical start/stop date on this in relation to reporting. However, the contract ends in September 2013 so it is possible if OMB clearance is significantly delayed, we would not be able to complete 5 quarterly calls. |
Analysis plan. All qualitative data will be analyzed using Atlas.ti software, a program designed to facilitate the analysis of qualitative data. This software helps to organize the large amount of qualitative information gathered from different data sources so we can identify and analyze common themes and contrasting points of view. The analysis plan for the cost and enrollment analysis includes creating a separate spreadsheet for each state, which will capture all requested quantitative data. For example, we will note all steps that differed between traditional enrollment and the non-ELE process being studied, and the staff time and salary estimate of contractor costs associated with each step. We will ask the states to verify the information. In all cases, we will seek to obtain the total state and federal combined costs, or to adjust costs to account for the state Federal Medical Assistance Percentage rate if we receive data only on state expenditures. After receiving this data, we will convert each reported cost element into a cost-per-enrolled-child measure, and sum the costs from each step to estimate the ongoing difference in cost per new non-ELE approach enrollee versus an enrollee entering through traditional enrollment routes. We will also separately report the initial fixed costs needed to implement the non-ELE approach under study. We will also construct an overall cost-per-enrolled child measure, dividing total non-ELE and traditional enrollment expenditures by the total number of non-ELE and traditional enrollees to understand whether global enrollment efficiency has changed with the introduction of the non-ELE method. Pre-implementation data will come from the states (as Attachment C shows, we are asking States to provide monthly enrollment data for the entire 12-month period before implementation of the policy).
The OMB number and expiration date will be displayed on every document seen by a respondent.
We are seeking no exceptions.
Aizer, Anna. “Low Take-Up in Medicaid: Does Outreach Matter and for Whom?” AEA Papers and Proceedings, vol. 93, no.2, May 2003, pp. 238-241.
Bansak, Cynthia, and Steven Raphael. “The Effects of State Policy Design Features on Take-Up and Crowd-Out Rates for the State Children Health Insurance Program.” Journal of Policy Analysis and Management, vol. 26, no.1, winter 2006, pp. 149-175.
Dorn, Stan, Bowen Garrett, Cynthia Perry, Lisa Clemans-Cope, and Aaron Lucas. “Nine in Ten: Using the Tax System to Enroll Eligible, Uninsured Children into Medicaid and SCHIP.” Washington, DC: Urban Institute, January 2009. Available at [http://www.urban.org/UploadedPDF/411844_tax_system.pdf]. Accessed July 31, 2011.
Kenney, Genevieve M., Victoria Lynch, Allison Cook, and Samantha Phong. “Who and Where Are the Children Yet to Enroll in Medicaid and the Children’s Health Insurance Program?” Health Affairs, vol. 29, no. 10, October 2010, pp. 1920-1929.
Kronebusch, Karl, and Brian Elbel. “Simplifying Children’s Medicaid and SCHIP.” Health Affairs, vol. 23, no. 3, May 2004, pp. 233-246.
1 Depending on the OMB clearance date, the last quarterly call needs to take place by July 2013.
2 May 2010 National Occupation Employment and Wages Estimates, United States. Electronically published by the Department of Labor, BLS, as Occupational Employment Statistics.
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